DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC?

Dual diagnosis in older adults:

A hidden epidemic?

A thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy

Adam J. Searby
BNurs(Hons) (RMIT), Grad Dip Ment H Nurs (RMIT), Grad Dip AOD Studies (Turning Point)

School of Health and Biomedical Sciences

College of Science, Engineering and Health
RMIT University

July, 2017
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? i

Declaration

I certify that except where due acknowledgement has been made, the work is that of the author
alone; the work has not been submitted previously, in whole or in part, to qualify for any other
academic award; the content of the thesis/project is the result of work which has been carried out
since the official commencement date of the approved research program; any editorial work, paid or
unpaid, carried out by a third party is acknowledged; and, ethics procedures and guidelines have
been followed.

I acknowledge the support I have received for my research through the provision of an Australian
Government Research Training Program Scholarship.

Adam J. Searby

July, 2017
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? ii

Acknowledgements

While writing this thesis, I have been fortunate to spend time at conferences both nationally and

overseas, and as a result have met many nurses who work with older adults with dual diagnosis.

Often, these nurses work in isolation and frustration at a lack of clinical guidance in providing care

to this population. Their conversations, anecdotes and suggestions have been invaluable, and I am

truly indebted to them and feel honoured to provide a voice to the importance of this work via this

thesis.

Likewise, during my time at the Mobile Aged Psychiatry Service (MAPS) I have been fortunate to

work with some exceptional clinicians who have demonstrated what it is to be a great mental health

nurse. Not only have they guided me during my career but have supported me on this path and for

that I am forever grateful.

My supervisors, Associate Professor Phil Maude and Dr Ian McGrath have given me the scope to

“run my own race” while conducting this research thesis, all while providing me with exceptional

guidance and mentorship. Their ability to turn my sometimes fanciful ideas into actual research

output is nothing short of amazing, as is their tendency to continually buy me coffee every time we

meet. I am forever grateful, both for the coffee and their skill at supervising research candidates like

me.

Finally, my family deserves the most acknowledgement for putting up with all of my writing days,

my need to finish “just one more journal article/transcript/chapter/revision,” and their patience with

my endless travel interstate and internationally to conferences. Now that this is done, my children,

Renae, Ava and Flynn get me back for relentless weekend sports, driving lessons and holidays. And

for my wife, Amber, who has never wavered in her belief that I will finish this thesis, this is for

you. Your patience during the last four years has been incredible.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? iii

Table of Contents

Declaration .............................................................................................................................. i

Acknowledgements ................................................................................................................. ii

Table of Contents ................................................................................................................... iii

Table of Figures ..................................................................................................................... xi

Abstract .................................................................................................................................. 1

Dissemination List .................................................................................................................. 4

Chapter One: Introduction .......................................................................................................... 8

Introduction ............................................................................................................................ 8

Scope of the Problem .............................................................................................................. 9

Significance of the Study .......................................................................................................11

Structure of the Thesis ...........................................................................................................13

Chapter Two: Background to the Study.....................................................................................14

Introduction ...........................................................................................................................14

Defining Dual Diagnosis ........................................................................................................17

DSM-V definition ..............................................................................................................18

Defining substance use - illicit versus licit..........................................................................19

A hidden epidemic? ...........................................................................................................21

The harm reduction/abstinence dichotomy.. .......................................................................23

Policy Directions ...................................................................................................................26

The Differences Between the Mental Health and Alcohol and Other Drugs Sector .................29

Workforce ..........................................................................................................................31

Mandated versus voluntary care .........................................................................................33

An Overview of the Aged Person's Mental Health System in Victoria ....................................37

Summary ...............................................................................................................................39
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? iv

Chapter Three: Literature Review .............................................................................................40

Introduction ...........................................................................................................................40

Search Strategy ......................................................................................................................40

Limitations Arising From the Literature .................................................................................42

Conceptualising Dual Diagnosis ............................................................................................43

Current research. ................................................................................................................44

The evolution of dual diagnosis as treatment concern .........................................................48

The apparent failure of the maturing out hypothesis ...........................................................53

The "lifetime" user .............................................................................................................59

The Extent of the Problem .....................................................................................................63

Prevalence of AOD use in the aged cohort .........................................................................64

Costs of care ......................................................................................................................68

Contrasting the aged cohort with the adult psychiatric population ......................................72

Neuropsychological effects of substance abuse ..................................................................76

Suicide and risky behaviours ..............................................................................................81

Contemporary Treatment .......................................................................................................85

Screening tools specific to the aged cohort .........................................................................85

Contemporary treatment approaches ..................................................................................88

Clinician attitudes to dual diagnosis ...................................................................................93

Future Challenges ..................................................................................................................97

Methamphetamine..............................................................................................................97

An ageing methadone population ..................................................................................... 101

The baby boomer generation ............................................................................................ 106

Summary ............................................................................................................................. 110

Chapter Four: The Research Process ....................................................................................... 111

Introduction ......................................................................................................................... 111

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? v

An Overview of the Research Process .................................................................................. 111

Setting of the Study.............................................................................................................. 112

The Mixed Methods Design ................................................................................................. 114

Defining mixed methods. ................................................................................................. 114

A brief history of mixed methods. .................................................................................... 116

The explanatory sequential design. ................................................................................... 117

Rationale for the use of a Mixed Methods Design ............................................................ 118

Phase One ............................................................................................................................ 120

Description ...................................................................................................................... 120

Inclusion and exclusion criteria ........................................................................................ 121

Method ............................................................................................................................ 121

Development of the audit tool .......................................................................................... 122

Reliability and validity ..................................................................................................... 123

Data analysis .................................................................................................................... 124

Phase Two ........................................................................................................................... 124

Description ...................................................................................................................... 125

Sampling process ............................................................................................................. 125

Inclusion/exclusion criteria .............................................................................................. 126

Method ............................................................................................................................ 127

Development of the semi-structured interview questions .................................................. 127

Rigour .............................................................................................................................. 128

Challenges of the second phase ........................................................................................ 131

Phase Three ......................................................................................................................... 133

Description ...................................................................................................................... 133

Sampling Process ............................................................................................................. 133

Method ............................................................................................................................ 134

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? vi

Development of the semi-structured interview questions .................................................. 134

Rigour .............................................................................................................................. 135

Data Analysis ................................................................................................................... 135

Ethical Considerations ......................................................................................................... 135

Vulnerable populations .................................................................................................... 136

Informed consent ............................................................................................................. 137

Payment for interview. ..................................................................................................... 138

Researcher safety ............................................................................................................. 139

Summary ............................................................................................................................. 141

Chapter Five: Phase One: Results of the File Audit Process ................................................... 142

Introduction ......................................................................................................................... 142

Descriptive Statistics of the Sample ..................................................................................... 143

The Dual Diagnosis Group................................................................................................... 145

Gender. ............................................................................................................................ 146

Age .................................................................................................................................. 146

Substances used ............................................................................................................... 147

Mental health diagnosis .................................................................................................... 149

Comorbid health conditions ............................................................................................. 150

Qualitative Analysis of the Assessment Process ................................................................... 152

Lack of documentation ..................................................................................................... 153

Poor understanding of alcohol guidelines. ........................................................................ 154

Referral for AOD treatment.............................................................................................. 155

Summary ............................................................................................................................. 156

Chapter Six: Phase Two: Findings From In-Depth Client Analysis and Interview................ 157

Introduction ......................................................................................................................... 157

The Second Phase ................................................................................................................ 157

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? vii

Participant Background ........................................................................................................ 158

Participant one ................................................................................................................. 159

Participant two ................................................................................................................. 160

Participant three ............................................................................................................... 161

Participant four ................................................................................................................ 162

Participant five ................................................................................................................. 163

Participant six .................................................................................................................. 164

Content Analysis .................................................................................................................. 165

The notion of addiction as career...................................................................................... 165

Onset............................................................................................................................ 166

The need to use overriding all else................................................................................ 170

Changing drug worlds. ................................................................................................. 175

"We are dying of things normal people die of." ............................................................ 177

Patterns of drug use .......................................................................................................... 180

Adaptive use ................................................................................................................ 181

Contemplating changes to use ...................................................................................... 184

The concept of self-medication..................................................................................... 187

Complexity ...................................................................................................................... 190

Medical conditions ....................................................................................................... 191

Stigma.......................................................................................................................... 195

A system not catering to older adults ............................................................................ 198

The drug and the mental illness ........................................................................................ 200

Treatment experiences: mental health ........................................................................... 201

Treatment experiences: AOD ....................................................................................... 205

Treatment experiences: MAPS ..................................................................................... 208

Summary ............................................................................................................................. 211

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? viii

Chapter Seven: Phase Three: Findings From Staff Interviews ............................................... 212

Introduction ......................................................................................................................... 212

The Third Phase ................................................................................................................... 212

Content Analysis .................................................................................................................. 213

Assessment and response ................................................................................................. 213

Assessment issues ........................................................................................................ 214

Cultural considerations ................................................................................................. 218

"Not our business."....................................................................................................... 221

Educational preparedness ............................................................................................. 224

Clinician experiences ....................................................................................................... 228

Clinical experience ....................................................................................................... 228

Clinical helplessness .................................................................................................... 232

Therapeutic nihilism..................................................................................................... 236

Family and carer issues ................................................................................................ 238

Service collaboration........................................................................................................ 241

Discharge pressure ....................................................................................................... 242

Referral difficulty......................................................................................................... 244

Intersectorial collaboration ........................................................................................... 247

Improvements to service delivery. ................................................................................ 249

Summary ............................................................................................................................. 253

Chapter Eight: Discussion and Implications ............................................................................ 254

Introduction ......................................................................................................................... 254

Discussion ........................................................................................................................... 254

Deficiencies in screening and assessment ......................................................................... 254

Exploring the difference between this research and other studies .................................. 255

A lack of assessment tool use ....................................................................................... 257

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? ix

Can clinicians rely on clinical judgment? ..................................................................... 260

Complexity ...................................................................................................................... 264

A poorly understood population ................................................................................... 264

Perceptive simplicity of the term “dual diagnosis.” ....................................................... 266

Siloed care ................................................................................................................... 268

Workforce readiness ........................................................................................................ 271

Educational preparation................................................................................................ 272

The utility of training. .................................................................................................. 274

A lack of intersectorial collaboration ............................................................................ 276

System response. .............................................................................................................. 278

"Not our business."....................................................................................................... 279

A rigid service delivery model...................................................................................... 281

Setting.......................................................................................................................... 283

Limitations of the Research.................................................................................................. 285

Strengths of the Research ..................................................................................................... 288

Recommendations for Future Research ................................................................................ 289

Screening tools................................................................................................................. 290

Specific cohort studies ..................................................................................................... 291

Exploring adaptive use ..................................................................................................... 291

Cognitive impairment....................................................................................................... 292

Specific treatment services ............................................................................................... 293

Comprehensive interventions ........................................................................................... 294

Adapting harm reduction .................................................................................................. 295

Summary ............................................................................................................................. 295

Chapter Nine: Recommendations for Service Improvement and Concluding Statements..... 297

Introduction ......................................................................................................................... 297

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? x

Recommendations ................................................................................................................ 297

1. Screening ..................................................................................................................... 297

2. Expanding practice domains ......................................................................................... 299

3. Collaborative service linkages ...................................................................................... 300

4. Streamlining referral processes ..................................................................................... 301

5. Clinical specialisation .................................................................................................. 303

6. Investigating appropriate treatment options .................................................................. 304

7. Upskilling the workforce .............................................................................................. 306

Concluding Statements ........................................................................................................ 307

References .................................................................................................................................. 311

Appendix A: Ethical Approval Statements ........................................................................... 353

Appendix B: Participant Information and Consent Forms (PICFs) ....................................... 355

Appendix C: File Review Tool............................................................................................. 364

Appendix D: Semi-Structured Interview Questions .............................................................. 365

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? xi

Table of Figures and Tables

Figure 1. The literature search process. ..........................................................................................42

Figure 2. Graphical representation of the MAPS geographical catchment area. ............................ 113

Figure 3. Mixed methods study flow. ........................................................................................... 117

Figure 4- Braun and Clarke's (2006) coding flow as applied to phases two and three ................... 130

Figure 5. Flowchart of Phase One study process. ......................................................................... 143

Figure 6. Suburbs of residence for the sample. ............................................................................. 145

Figure 7. Boxplot of age, grouped by AOD use status. ................................................................. 147

Figure 8. Substances recorded in assessment documentation. ....................................................... 148

Figure 9. Substances recorded grouped by gender. ....................................................................... 149

Figure 10. Mental health diagnoses in both cohorts. ..................................................................... 150

Table 1. Summary descriptive statistics of the sample. ................................................................. 144

Table 2. Medical conditions grouped by dual diagnosis status and gender. ................................... 151
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 1

Abstract
Dual diagnosis in older adults, defined as co-occurring mental ill health and alcohol and other drug

(AOD) use disorders, is a poorly researched phenomenon in the older adult cohort that leads to

suboptimal health outcomes, higher rates of psychiatric relapse and poor treatment engagement.

Despite the recognition of the issues associated with dual diagnosis in younger mental health

consumers, assessment and treatment options remain poor for their older counterparts. Likewise,

few treatment settings are equipped to cater to the complexity inherent in older adults having dual

diagnosis.

This thesis examines dual diagnosis in the context of an inner Melbourne community older adult

mental health service, providing crisis assessment, case management and liaison services to

individuals aged 65 and over. The aims of this research were to identify the prevalence of dual

diagnosis in the service, describe the experiences of consumers in the service with dual diagnosis

and the experiences of the clinicians providing care for them. This thesis accomplishes these aims

by using an exploratory mixed methods framework, the explanatory sequential design.

The first phase of the thesis uses a file audit methodology to determine the prevalence of concurrent

AOD use in individuals assessed by the community mental health service for a two-year period,

June 2012-2014 (n=594). Through this process, 93 (15.5%) individuals were identified by clinicians

of the mental health service to have problematic AOD use, which was recorded on a simple yes/no

checkbox on an electronic assessment document. Of those recorded as using AOD, 65.2% were

male and predominantly used alcohol.

The second phase of the project sought to interview consumers with dual diagnosis (n=6) who were

identified by clinicians of the service as being difficult to provide care for due to their dual

diagnosis. This phase identified themes of longstanding, fluid addiction careers and the notion that

older adults often “adapt” their substance use as previously identified in the literature. It also
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 2

identified the complexity inherent in older adults with combined mental ill health, AOD use

disorders and medical conditions, highlighting the relative simplicity of the term dual diagnosis and

its applicability in the older adult cohort.

The final phase of the project interviewed clinicians of the mental health service (n=10) to

determine their experiences of providing care for older adults with dual diagnosis. The interview

schedule for this phase was informed by both the initial phase of the research and the results of the

consumer interview process. This phase identified the frustration evident in caring for older adults

with dual diagnosis, and highlighted poor knowledge and inconsistent assessment techniques. The

lack of perceived progress in this consumer cohort also led to a feeling of clinical helplessness,

ending in therapeutic nihilism where it was felt that nothing could be done to change longstanding

patterns of AOD use.

As an exploratory study, this thesis identifies a number of substantial issues in the care provided to

older adults with dual diagnosis, and acts as a strong foundation study to inform future research into

this cohort. Assessment of older adults with AOD use was found to be poor, with clinicians

reporting poor service linkages and difficulty in identifying appropriate treatment options for older

adults with dual diagnosis in their care. This thesis makes a number of recommendations for service

improvement and future research, including implementing enhanced assessment, exploring wider

populations of older adults with dual diagnosis and policy changes.

Older adults with AOD use disorders have been labeled as “invisible addicts” in the media due to

poor assessment and recognition of AOD use in this cohort. This thesis adds support to this

argument, identifying poor assessment and service provision to older adults with both mental ill

health and AOD use disorders. Given demographic changes in Australia, which include the ageing
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 3

baby boomer cohort, the time to investigate and implement improved care to older adults is

imperative to avoid a hidden epidemic.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 4

Dissemination List

Sections of this thesis have been disseminated as follows:

Peer Reviewed Journal Articles

Searby, A., Maude P., & McGrath, I. (2015). Dual diagnosis in older adults: A review. Issues in

Mental Health Nursing, 36(2), 104-111.

Searby, A., Maude, P. & McGrath, I. (2015). Growing old with ice: A review of the potential

consequences of methamphetamine abuse in Australian older adults. Journal of Addictions

Nursing, 26(2), 93-98.

Searby, A., Maude, P., & McGrath, I. (2015). Maturing out, natural recovery and dual diagnosis:

What are the implications for older adult mental health services? International Journal of

Mental Health Nursing, 24(6), 478-484.

Searby, A., Maude, P., & McGrath, I. (2015). An ageing methadone population: A challenge to

aged persons’ mental health services? Issues in Mental Health Nursing, 36(11), 927-931.

Searby, A., Maude, P., & McGrath, I. (2016). Prevalence of co-occurring alcohol and other drug

use in an Australian older adult mental health service. International Journal of Mental

Health Nursing, 25(2), 151-158.

Searby, A., Maude, P., & McGrath I. (2017). The experiences of clinicians caring for older adults

with dual diagnosis: An exploratory study. Issues in Mental Health Nursing, 38(10), 805-

811.

Searby, A., Maude, P., & McGrath I. (2018). The experiences of older adults with dual diagnosis in

an inner Melbourne community mental health service. Issues in Mental Health Nursing.

(Accepted and in press).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 5

Other Articles

Searby, A., Maude, P., & McGrath, I. (2015). Drugs, alcohol, older adults and mental health:

Caring for the invisible addicts. Australian Nursing and Midwifery Journal, 22(10), 41.

Peer Reviewed Conference Presentations

Searby, A., Maude, P., & McGrath, I. (2014). Maturing out, dual diagnosis and natural recovery:

What are the implications for aged psychiatry services? Victorian Collaborative Psychiatric

Nursing Conference, Melbourne.

Searby, A., Maude, P., & McGrath, I. (2014). Dual diagnosis in older adults: A hidden epidemic?

Australian College of Mental Health Nurses 40th International Mental Health Nursing

Conference, Melbourne.

Searby, A., Maude, P., & McGrath, I. (2014). The prevalence of substance use in an aged

psychiatry community service (poster presentation). Australian Professional Society on

Alcohol and Other Drugs (APSAD) Conference, Adelaide.

Searby, A., Maude, P., & McGrath, I. (2015). Dual Diagnosis in Older Adults: The Experience of

an Inner Melbourne Community Mental Health Service. International Society of Psychiatric

–Mental Health Nurses (ISPN) Psychopharmacology Institute and Annual Conference,

Seattle, USA.

Searby, A., Maude, P., & McGrath, I. (2015). Problematic alcohol consumption in older adults:

Why all nurses need to be concerned. In proceedings, 3rd Worldwide Nursing Conference,

Singapore.

Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: Implications for

services. Australian Winter School Conference, Brisbane.

Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: Prevalence and service

user experiences. (Poster presentation). Australian Winter School Conference, Brisbane.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 6

Searby, A., Maude, P., & McGrath, I. (2015). Older adults: The hidden faces of addiction? Drug

and Alcohol Nurses of Australia (DANA) Many Faces of Addiction Forum, Sydney.

Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: Prevalence and service

user experiences. Drug and Alcohol Nurses of Australia (DANA) Many Faces of Addiction

Forum, Sydney.

Searby, A., Maude P., & McGrath, I. (2015). Dual diagnosis in older adults: Prevalence in an inner

Melbourne community mental health service. Australasian Professional Society on Alcohol

and Other Drugs (APSAD) Scientific Conference, Perth.

Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: Prevalence and service

user experiences. (Poster presentation). Australasian Professional Society on Alcohol and

Other Drugs (APSAD) Scientific Conference, Perth.

Searby, A., Maude, P., & McGrath, I. (2016). Exploring Co-Occurring Substance Use Disorder in

an Older Adult Population: Case Studies and Exploration of the

Contemporary Evidence Base. International Society of Psychiatric –Mental Health Nurses

(ISPN) Psychopharmacology Institute and Annual Conference, Minneapolis, USA.

Searby, A., Maude, P., & McGrath, I. (2016). The Future is Now: Change in Older Adult Mental

Health Services to Meet Future Challenges. International Society of Psychiatric –Mental

Health Nurses (ISPN) Psychopharmacology Institute and Annual Conference, Minneapolis,

USA.

Searby, A., Maude, P., & McGrath, I. (2016). Dual Diagnosis in Older Adults: Prevalence and

Service User Experiences. (Poster presentation). International Society of Psychiatric –

Mental Health Nurses (ISPN) Psychopharmacology Institute and Annual Conference,

Minneapolis, USA.

Searby, A., Maude P., & McGrath, I. (2016). Older adults: The hidden faces of addiction?

International Nurses Society on Addictions 40th Annual Educational Conference, Las

Vegas, USA.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 7

Searby, A., Maude P., & McGrath, I. (2016). Dual diagnosis in older adults: Prevalence and service

user experiences. (Poster presentation). International Nurses Society on Addictions 40th

Annual Educational Conference, Las Vegas, USA.

Searby, A., Maude P., & McGrath, I. (2017). Addressing the hidden faces of addiction: Alcohol and

other drug use in older adults. (Poster presentation). International Nurses Society on

Addictions 41st Annual Educational Conference, Orlando, USA. (Abstract accepted).

Invited and Keynote Presentations

Searby, A., Maude, P., & McGrath, I. (2015). Dual diagnosis in older adults: Implications for

services. Building Up Dual Diagnosis Holistic Aged Services (BUDDHAS) Conference,

Melbourne, (invited speaker).

Other Conference Presentations

Searby, A., Maude, P., & McGrath, I. (2014). Dual diagnosis in older adults: A hidden epidemic?

(Poster presentation). Alfred Health Week: Caulfield Hospital Research, Quality

Improvement and Service Promotion Poster Competition, Melbourne.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 8

Chapter One

Introduction

“You’ll be disappointed here. We don’t get much substance use at all.”

Clinician to the author on his first day as a MAPS case manager.

Introduction

Dual diagnosis is a complex phenomenon increasingly encountered in contemporary mental

health services (Victorian Government Department of Human Services, 2007). Dual diagnosis

refers to co-occurring mental ill health and alcohol and other drug (AOD) use disorders, and has

been noted to lead to poor treatment outcomes and increased risk of relapse in addition to higher

treatment costs and a greater treatment burden on both community and inpatient mental health

services (Kenneth Minkoff & Cline, 2006).

Dual diagnosis in older adults has been seldom studied and is often regarded, in a population

sense, as an insignificant problem (Prigerson, Desai, & Rosenheck, 2001). However, an ageing

population combined with a propensity for greater drug and alcohol use is set to challenge this

notion (Bartels, Blow, Brockmann, & Van Citters, 2005). A number of substance using populations,

such as those undergoing methadone maintenance therapy, are also ageing and are destined to

further challenge the provision of mental health and substance use treatment services to a growing

consumer base with increasingly complex needs (Rosen, Hunsaker, Albert, Cornelius, & Reynolds,

2011).

The Victorian Government’s 2007 document Dual diagnosis: Key directions and priorities

for service development recognised the challenges of an increasing number of dual diagnosis
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 9

presentations to mental health services, recommending greater integration of both mental health and

AOD treatment systems, improved treatment for clients and greater support for carers and families

of individuals with dual diagnosis. The report also sought to make dual diagnosis “core business”

within mental health services. Despite the recognition of improved treatment frameworks as

beneficial to both individuals and service providers, co-occurring substance use is often considered

ancillary to mental ill health in contemporary mental health services, continuing a fragmented

approach to concurrent treatment and management of substance use (Munro & Edward, 2008).

The setting of this study is the Caulfield Hospital Mobile Aged Psychiatry Service, a

publicly funded community mental health service providing assessment, crisis response and case

management to adults aged 65 and over in the inner south area of metropolitan Melbourne. The

service has an ongoing caseload of approximately 150 clients per month, and is operated under a

multidisciplinary framework, with a psychiatrist, psychiatric registrar, psychologist, registered

nurses, occupational therapists and social workers forming the MAPS team. This research aims to

explore dual diagnosis service utilisation and client experiences in the context of this service.

Scope of the Problem

Older adult mental health services face a number of significant challenges over the coming

decades related to dual diagnosis. Currently, research indicates the majority of older adults with

dual diagnosis involved with mental health services use alcohol (Wang & Andrade, 2013). The

ageing of the baby boomer cohort is likely to see not only an increase in AOD use, but also a wider

variety of substances than traditionally used by older adults, as indicated by research showing that

this may be due to the exposure of this generation to drug use in youth (Cangelosi, 2011).

Another factor is the trend towards the abuse of prescription medications, such as opiates

and benzodiazepines (Simoni-Wastila & Yang, 2006). Added to the emergence of substances with
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 10

an as yet unknown effect on the human body over time, such as methamphetamine, and the

potential for older adult mental health services to need to respond to a wide range of complications

of substance abuse disorders is substantial, requiring a considered response to provide services to

those in need within the fiscal confines of ever expanding healthcare expenditure.

Perhaps the most concerning element of dual diagnosis in older adults is the notion of an

ageing population. Studies in the United States of America have indicated that the number of older

adults with mental health or substance use disorders will virtually double by the year 2030 (Bartels

& Naslund, 2013), with a similar trend likely to occur in Australian settings. Unfortunately,

research has not kept pace with this expected influx of older adults requiring services, with research

attention in this cohort being described as “unpopular” and discouraged due to the notion that older

adults using substances either die prematurely due to the rigours of drug-using lifestyles or

recovering spontaneously with little input from mental health services (Badrakalimuthu, Rumball,

& Wagle, 2010).

Dual diagnosis presentations to mental health services carry a substantial financial cost, both

in terms of direct service provision and loss of productivity to society. Individuals with dual

diagnosis often require extensive inpatient treatment under restrictive interventions, and as

mentioned in the introduction, often have poorer treatment outcomes in comparison to individuals

with a mental illness alone (Brady et al., 1996). With a burgeoning population of adults ageing into

aged psychiatry services, it is essential to explore dual diagnosis in older adults in a local context in

order to facilitate effective responses to what may be the greatest challenge to aged psychiatry

services in the future.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 11

Significance of the Study

The creation of this thesis emerged from the author’s experiences in adult mental health

inpatient wards, where dual diagnosis was indeed the status quo. A sizeable proportion of

individuals discharged from the wards often returned to polysubstance use immediately after

leaving the hospital, however the author’s experience was that substance use was largely ignored, or

abstinence dictated as being of benefit to an individual’s mental health. After moving to a case

management role in the Mobile Aged Psychiatry Service (MAPS) at Caulfield Hospital in

Melbourne, Victoria, the author found a small population of older adults managed by MAPS with

co-occurring substance use disorders. Often, these individuals received very little support

concerning their substance use disorder and provoked a large degree of anxiety and debate amongst

the team regarding their management.

To date, no Victorian study has explored service response to dual diagnosis in older adults.

Much of the published literature concerning dual diagnosis in older adults emanates from the

United States, leaving the Australian perspective of this challenging problem unexplored. This

study, although attempting to address the dearth of local literature concerning dual diagnosis in

older adults, is primarily envisaged as a service improvement project. Accordingly, the core aims of

this study relate to improvement of MAPS in its response to dual diagnosis. To this end, the

ultimate goal of the study is to guide the formation of service delivery where dual diagnosis is

treated effectively and humanely, while being guided by consumer and clinician experience.

Accordingly, this study is significant in that it intends to harness this knowledge to position

MAPS as a model service in providing care to older adults with dual diagnosis. To facilitate this

goal, this study takes place in three methodological phases. The first phase involves a file audit

process, examining admissions and assessments undertaken by the service in order to determine the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 12

prevalence of substance use disorders within MAPS core client population. A number of

demographic variables are also examined in this process.

The second phase of the study employs a qualitative, semi-structured interview process to

describe the experiences of consumers of MAPS services. History data for each of the participants

is also explored, both to demonstrate the course of their dual diagnosis and explore previous

interactions with both mental health and drug and alcohol services. The participants’ experiences

with services are also explored in order to guide the recommendations of this thesis in accordance

with the principles of consumer involvement and service guided by consumer experience (Hare,

Law, & Brennan, 2013; Salzer, 1997).

The third and final phase of this study also employs a semi-structured interview

methodology to define the experiences of clinicians from the MAPS team in caring for older adults

with dual diagnosis, and in formulating improved care for older adults experiencing dual diagnosis.

This phase of the research seeks to engage clinicians to develop procedures and service response to

dual diagnosis, in addition to enabling clinicians to evaluate their own practices and introduce

change (Davison, Hauck, Martyr, & Rock, 2013). This design has been based on the atheoretical

model of “practice-based evidence,” as proposed by Leeman and Sandelowski (2012).

This study holds significance in that it proposes change driven by both consumer and

clinician. It is guided by the experiences of individuals as both consumers of MAPS services and

clinicians providing care to older adults with dual diagnosis, and provides recommendations to

develop dual diagnosis capacity within the Caulfield Hospital Aged Psychiatric Service to a level

whereby timely assessment and efficient, compassionate, cost effective care is achieved with every

individual utilising MAPS services.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 13

Focus and Research Questions

The focus of this study is the phenomenon of dual diagnosis in older adults and how it is

currently managed within an inner Melbourne community mental health service. The key research

questions guiding this study are:

1. Does the Caulfield Hospital Mobile Aged Psychiatry Service care for a significant dual

diagnosis population, and if so, how does this population appear demographically?

2. What are the experiences of older adults with dual diagnosis who receive care from the

Caulfield Hospital Mobile Aged Psychiatry Service?

3. What are the experiences of Caulfield Hospital Mobile Aged Psychiatry Service clinicians

caring for the older adult dual diagnosis cohort, and can these experiences inform future

service transformation to improve care?

Structure of the Thesis

This thesis is arranged in nine chapters. The second chapter provides a background to the

study. The third chapter provides a review of contemporary literature concerning dual diagnosis in

older adults. Chapter Four describes the research process of the study, while Chapter Five explores

the results of the quantitative phase of the study. Chapters six and seven describe the qualitative

findings of the study concerning service users and clinicians. In Chapter Eight the findings of the

study are discussed along with their implications. Chapter Nine provides a number of

recommendations for service improvement and concludes the thesis.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 14

Chapter Two

Background to the Study

Introduction

A dichotomy exists between the mental health and the alcohol and other drug treatment

sectors, who often operate with quite divergent workforces, treatment priorities and legislative

structures informing their overall service mandate (Flatau et al., 2013). This disjunction is most

evident when examining the Mental Health Act, which enables authorised mental health services to

dictate compulsory care of individuals who meet the criteria for a mental illness that requires

immediate treatment due to imminent risk to the individual or community, deterioration in health,

and no less restrictive means to provide this treatment (Parliament of Victoria, 2014).

Recent efforts to introduce compulsory treatment in drug and alcohol treatment cohorts have

resulted in a number of concerns (Hall et al., 2012; Hall, Farrell, & Carter, 2014). Although

legislation does exist within substance use treatment spheres to compel individuals to treatment,

being the Severe Substance Dependence Act (2010), it is rarely used (Medew, 2012). Individuals

are often mandated treatment by the judicial system, through the use of court orders, which are

often criticised as to their lack of success (Klag, O'Callaghan, & Creed, 2005). In spite of these

legislative avenues, the alcohol and other drug treatment system largely operates guided by an

individual’s willingness to engage and participate in treatment.

Another key point of difference between the two treatment systems is the debate between

harm minimisation and abstinence. Alcohol and other drug services often work under a harm

reduction framework, offering advice to individuals who continue using substances in order to

reduce the harm that may come from using these substances (Ball, 2007). Needle exchanges,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 15

primary outreach health programs and supervised injecting clinics are examples of programs

working under a harm reduction paradigm. This concept is in its infancy in Victorian mental health

services, who may ascribe to harm reduction at a policy level, however often employ clinicians who

insist on abstinence as the only goal of AOD treatment due to the increased rate of relapse and

deleterious effects AOD use may have on an individual’s mental state (Mancini & Linhorst, 2010).

When considering that individuals with co-occurring substance use disorders and mental

illness often need to access both treatment systems, the opposing paradigms of each become more

relevant. While compulsorily treated in a mental health system, often as an inpatient in a psychiatric

ward of a public hospital, individuals with dual diagnosis may encounter significant roadblocks in

their attempts to access treatment from alcohol and other drug services. Often, these roadblocks

may be related to their psychiatric disability or perceived readiness to change (Ouimette et al.,

2007). It is these factors that lead researchers to discuss the notion of integrated treatment as

integral to the successful management of substance use disorders in the context of dual diagnosis.

The intention of this chapter is to discuss these background issues as they relate to the

phenomenon of dual diagnosis in older adults. Contemporary research has attempted to explore

these concerns in the adult mental health setting, however they become more relevant to the

contemporary older adult mental health services who have seen little in the way of challenges from

complex dual diagnosis presentations (Bartels, Blow, Van Citters, & Brockmann, 2006). Older

adult mental health services have traditionally seen a number of individuals who use alcohol as a

primary substance whereas the ageing consumer of adult mental health services is likely to use a

number of substances (polysubstance use), including amphetamines, prescription benzodiazepines

and opiates (Shah & Fountain, 2008).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 16

Inception of the Topic and Personal Reflection

The impetus for exploration of this topic came from the author’s experiences in acute adult

inpatient mental health services, where dual diagnosis is quickly becoming the status quo; estimates

of up to 70% of inpatient populations having co-occurring lifetime substance use disorders have

been recorded in the literature (Ogloff, Lemphers, & Dwyer, 2004). The complexity of co-occurring

substance use disorders in severe mental illness led me to complete a Graduate Diploma in Alcohol

and Other Drug Studies, which also had the advantage of providing an insight into the alcohol and

other drug treatment system. It also allowed me to discuss the contemporary situation of dual

diagnosis with clinicians who worked solely in substance use treatment domains. The ideas that

were presented in the existing literature regarding the longitudinal progression of alcohol and other

drug use, as well as substance use disorders in older people, needed further exploration to

understand AOD use patterns in an older population.

My move to the Caulfield Hospital Mobile Aged Psychiatry Service (MAPS) was driven by

a desire to experience community mental health nursing; however this move also allowed me to

explore dual diagnosis in older adults. As the opening line to this thesis indicates, dual diagnosis

was not considered to be a concern in an older population. Through participating in clinical

discussion and case management of consumers of the service, it quickly became apparent that there

was a cohort of individuals with co-occurring mental illness and AOD use disorders. Examining the

literature surrounding the topic of dual diagnosis in older adults led to the discovery of a small

number of studies, which was in stark contrast to my experiences in the under 65 age group, where

dual diagnosis is heavily researched and written about.

The combination of a lack of research, along with my experiences case managing a group of

individuals with both long experiences of mental health services and drug and alcohol use led to the

development of the research questions of this thesis. Given that the limited studies concerning dual
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 17

diagnosis in older adults are mainly based on quantitative analysis of prevalence, there appeared to

be a need for a study exploring service provision, and the experiences of both users and providers of

this service. The aim of this study would be to illustrate both the nature and complexity of dual

diagnosis in older adults and the utility of empowering clients and clinicians to formulate service

improvement recommendations that are realistic, cost effective and achievable.

Defining Dual Diagnosis

Dual diagnosis is currently defined as a DSM-V mental illness diagnosis in tandem with a

substance use disorder (Smith & Morris, 2010). Early literature sometimes describes this

phenomenon as co-existing severe mental illness and substance use or abuse, or dual disorder

(Clark & Drake, 1994). In spite of this ambiguity, contemporary mental health services in Victoria,

Australia regard dual diagnosis as defined: mental illness in conjunction with AOD use (Victorian

Government Department of Human Services, 2007).

In terms of the older adult mental health population, dual diagnosis is a term that often

encompasses more than two diagnoses. Older adults often present to mental health services with

complex health needs in addition to mental health and substance use disorders, making the notion of

dual diagnosis somewhat arbitrary (Moos, Mertens, & Brennan, 1995). As individuals with dual

diagnosis age, they are likely to encounter a number of challenges to their physical health as a result

of lifestyle, licit and illicit substance use and potentially the adverse effects of pharmacotherapy

used for psychiatric treatment (Robson & Gray, 2007). Throughout this thesis, although dual

diagnosis is used to define a co-existing mental illness and AOD use disorder, recognition should be

given to the complexities that go beyond this diagnosis in the older adult population, as explored in

the discussion section of this thesis.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 18

Although the definition itself of dual diagnosis is simple in respect of terminology, it

remains one of the greatest challenges to contemporary mental health services (Cleary, Walter,

Hunt, Clancy, & Horsfall, 2008). The growing prevalence of comorbid substance use disorders and

mental illness in the adult (under 65) mental health setting is concerning, not least due to higher

rates of relapse, greater severity of psychotic symptoms and behavioural outcomes that often

manifest as violence and aggression (Brady et al., 1996). Although, as demonstrated in Chapter

Five of this thesis, the older adult mental health cohort does not experience as high a prevalence of

dual diagnosis, ageing adult mental health consumers often show no signs of abating their AOD use

(Beynon, 2008). This phenomenon, along with late-onset commencement of substance use in older

adults, indicate a challenge to older adult mental health services and looks certain to require

changes in service delivery in order to meet the needs of this complex consumer cohort.

DSM-V definition.

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V),

published by the American Psychiatric Association (2013) is a manual of diagnostic criteria for

mental health and substance use disorders. The DSM-V does not define set criteria for dual

diagnosis, instead providing diagnostic markers of both mental illness and what are defined as

“substance related and addictive disorders,” (p. 481). Use of the DSM-V informs most psychiatric

practise worldwide, both providing the nomenclature for conditions and discussion of features,

development, course of illness and prevalence. The DSM-V also adopts a common set of diagnostic

criteria for substance use disorders, further classifying each disorder according to substance used

(i.e. Alcohol use disorder). Within each disorder, the diagnostic criteria remain the same:

A problematic pattern of [substance] use leading to clinically significant impairment or distress, as manifested by at least

two of the following, occurring within a 12-month period:

1. [The substance] is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control [substance] use.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 19

3. A great deal of time is spent in activities necessary to obtain [the substance], use [the substance], or recover from its

effects.

4. Craving, or a strong desire or urge to use [the substance].

5. Recurrent [substance] use resulting in a failure to fulfill major role obligations at work, school or home.

6. Continued [substance] use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by

the effects of [the substance].

7. Important social, occupational, or recreational activities are given up or reduced because of [substance] use.

8. Recurrent [substance] use in situations where it is physically hazardous.

9. [Substance] use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that

is likely to have been caused or exacerbated by [the substance].

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of [the substance] to achieve intoxication or desired effect.

b. A markedly diminished effect with continued use of the same amount of [the substance].

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for [the substance].

b. [The substance] (or a closely related substance … ) is taken to relieve or avoid withdrawal symptoms.

(p. 491).

“Substance use disorder” is an umbrella term in the DSM-V, used to label a spectrum of use

from mild to moderate. The DSM-V also identifies a range of diagnostic criteria for the mental

illnesses primarily experienced by consumers of aged psychiatric services, such as schizophrenia,

bipolar disorder, depression and personality disorders, however in the interests of brevity the

diagnostic criteria for each disorder is not presented in this background chapter. It should be noted

that although the DSM-V is specifically developed by the discipline of psychiatry, these definitions

are often adopted by alcohol and other drug treatment services (Peer et al., 2013).

Defining substance use - illicit versus licit.

The use of substances in the modern day is difficult to define along the lines of legality.

Traditionally, substance use disorders would be qualified by the nature of the substance used,

whether licit (alcohol or prescription medications), or illicit (cannabis, amphetamines, heroin, etc.).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 20

However, this issue is becoming significantly more complex. Australia is experiencing a number of

individuals who obtain prescription medications through unlawful means, such as theft, prescription

diversion or “black market” sales of prescription medication lawfully obtained (Larance,

Degenhardt, Lintzeris, Winstock, & Mattick, 2011; Ling, Mooney, & Hillhouse, 2011).

In addition, a rising trend of polysubstance use is occurring in adult (under age 65) mental

health settings, whereby an individual using a number of licit and illicit substances in combination

complicates both the assessment and treatment of AOD use disorders occurring in tandem with

mental illness (Barnett et al., 2007). This diagnostic conundrum is pertinent in older adult mental

health settings, where the abuse of psychotropic medications has been noted to be an increasing

issue (Simoni-Wastila & Yang, 2006). Sensitive diagnosis of substance use disorders in older adults

is made more difficult due to the wide spectrum of both illicit and licit substances that may be used,

combined with the lack of clear guidelines determining safe or unsafe usage levels in older adults,

as is evidenced by alcohol use guidelines (McLaughlin et al., 2011).

As discussed in the next section, these factors contribute to the notion of the “hidden”

epidemic, and demonstrate the need for sensitive, accurate assessment of individuals under the care

of older adult mental health services. For example, a common description of use provided to

clinicians, as described further in Chapter Five, is “I only have one or two glasses a night.”

Quantification of this self-report is necessary, for a glass may be close to 500ml and the consumed

alcohol may be a spirit at 40% alcohol by volume (ABV). Similarly, an older adult consuming

benzodiazepines provided to them by a friend to “help with nerves” may be less likely to identify

this as a substance used, or problematic when considering their overall health.

The distinction between licit and illicit substances is becoming further blurred with the

proliferation of “synthetic” substances. Often, these substances can be bought over the counter in
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 21

tobacconists, sex shops or over the Internet. These substances are often changed chemically in order

to evade regulation, and may have variable effects (Khey, Stogner, & Miller, 2014). Older adults

may see no harm or need to identify substances that they have purchased legally, further making

accurate diagnosis and assessment challenging. As these challenges emerge in adult psychiatry, the

need for clinicians working with older adults to remain aware of the changing landscape of

substance use is necessary.

A hidden epidemic?

The title of this thesis is a reflection of a publication by the Royal College of Psychiatrists in

England titled Our Invisible Addicts (2011). The key premise of this document is that older adults

with AOD use disorder are effectively a growing population of individuals with high levels of

unmet need and complex psychiatric and medical co-morbidities. In addition, this report identifies

the notion that older adults often do not come to the attention of healthcare services until late in the

course of their AOD use disorder, when thorough investigation of incidents such as falls or familial

pressures often results in referral to mental health or alcohol and other drug services.

AOD use disorders may be longstanding or late onset as a result of psychosocial stressors.

Social withdrawal in these circumstances, as explored further in the literature review, adds pressure

to administer substance screening tools to older adults during every healthcare encounter (Dawe,

Loxton, Hides, Kavanagh, & Mattick, 2003). To date, little policy attention has been paid to older

adults, particularly in regard to local research; the Australian Institute of Health and Welfare

aggregates all “older adults” to a 40+ age group in its statistical data relating to illicit substance use,

making examination of the over age 65 cohort difficult (Australian Institute of Health and Welfare,

2011).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 22

The over 70 age group in Australia remains the most likely group to consume alcohol daily

(Australian Institute of Health and Welfare, 2011). The prevalence of the use of other substances in

this age group is less defined, however as illustrated in the literature review of this thesis, the

potential for a number of distinct sub-cohorts of older adults is relevant based on the primary

substance used and treatment modality the individual is engaged with. The most fitting example of

this is older adults who are maintained on opiate replacement therapy, primarily methadone.

Methadone clients are an ageing population whose interactions with healthcare providers can be

goal driven: visiting a general practitioner for a methadone script and a pharmacy for dispensing

(Doukas, 2011). Accordingly, this may make meeting their mental and physical health needs

difficult.

Research has found that stigma associated with drug use can also make users feel reluctant

to seek help (Conner & Rosen, 2008). A fear of incarceration or hospitalisation leading to a

separation from substance supply is another factor preventing older individuals from engaging with

services; transformation of roles in substance using circles may also occur as friends and

acquaintances either cease their use or die as a result of substance or medical complications, leaving

dually diagnosed individuals isolated and unlikely to come to the attention of services via report or

insistence of their peers, or incidentally through encounters with the law (Levy & Anderson, 2005)

In addition to the difficulties associated with assessing substance use in the older adult

population, a high degree of mood disorders is also prevalent. For example, an Australian Institute

of Health and Welfare report examining depression in residential aged care facilities found 45% of

individuals admitted to permanent aged care for the first time had symptoms of depression (2013).

Dementia is commonly referred to older adult mental health services for management and classed

as a mental health issue in later life. Dementia, while making treatment and management of co-

morbid substance use disorders challenging, raises questions around polypharmacy and dependence
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 23

on psychotropic medications such as benzodiazepines (Azermai, Bourgeois, Somers, & Petrovic,

2013; Clay, 2010).

Older adults present a complex array of factors that make assessment, diagnosis, treatment

and management of concurrent mental illness and substance use disorders problematic. They are

also more likely to seek treatment from primary health providers, indicating the importance of

collaborative linkages in management of this population (Bartels et al., 2005). The notion of the

hidden epidemic is especially relevant to high prevalence mental illness, such as the mood disorders

experienced in the aged population - which is a growing proportion of the population as the baby

boomer generation ages (Cangelosi, 2011). Added stressors of later life, such as loss of previous

roles, death of partner, friends and family combined with medical comorbidity and cognitive

impairment create an elevated risk profile for dual diagnosis in this population (Drugscope and the

Recovery Partnership, 2014).

The harm reduction/abstinence dichotomy.

As mentioned in the introduction to this background chapter, a significant contradiction

exists between mental health and alcohol and other drug services regarding a dominant paradigm:

harm minimisation or abstinence? As inferred in both terms, harm minimisation involves accepting

that individuals will continue to use AOD and both educating and implementing strategies to reduce

that harm (Roe, 2005). Abstinence, on the other hand, dictates a total cessation of all AOD use.

Within the AOD use treatment sphere, organisations adopt one of these dominant positions. For

instance, many community and religious organisations operate under a paradigm of abstinence,

where operation of a needle exchange or safe injecting facility requires an obvious deviation from

this position to one of harm reduction.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 24

Mental health services often fluctuate between their dominant paradigms, often attempting

to incorporate harm reduction principles however meeting resistance from staff who believe

cessation of drug or alcohol use is mandatory for an individual to truly recover from mental illness

(Marlatt & Witkiewitz, 2010). For example, this author has heard psychiatrists inform individuals in

an inpatient facility to cease their use, as it is the only way they would not relapse; I have also

witnessed a nurse berate a client for possessing clean injecting equipment. Harm reduction would

necessitate determining a stage of change for the individual, and if they were not committed to

ceasing their drug or alcohol use, working to minimise the harm inherent in substance use and abuse

(Australian Injecting & Illicit Drug Users League (AIVL), 2012). In this instance, exploring

reduced use, strategies for safer use and encouraging an individual when using clean injecting

equipment would be more useful stances than a straightforward, prohibitionist view that anything to

do with drugs is bad, dirty or disgusting with abstinence being the only way to achieve recovery

from mental ill health.

Prior to the commencement of this research, the author was required to case manage an

individual residing in a supported accommodation facility who had a long history of heavy drinking

leading to falls. This resident often left the facility before 8:00am to buy scotch whisky from a

nearby bottle shop, consuming it to the point of intoxication by 10:30am. Assessment of this

individual determined he was termed pre-contemplative about his substance use, meaning that he

did not feel a need to change his use at that point in time. The staff suggested sequestering his

finances in order to arrest his purchase of alcohol; a locked facility was explored to stop him

leaving. Both these options proved unrealistic, and it became necessary for the staff to adopt a harm

minimisation approach. Ultimately, the resident was in a supervised facility, close to medical

attention if required. The facility was opposite a large park, and there was a likelihood of forcing

the resident to consume alcohol in the park by restricting his consumption, which would leave him

vulnerable and in danger if falls occurred there. The discussion around allowing him to continue to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 25

drink on the premises was fraught with anxiety, and it took many months to reach a resolution

whereby he would limit his consumption to an agreed hourly level, with staff maintaining

possession of his alcohol. It wasn’t without a final word from the management of the facility

however, who required his family to sign a waiver indicating that he would not take any legal action

from injuries incurred whilst intoxicated.

This is not to dismiss abstinence as the ideal goal of any substance use disorder treatment,

particularly in the context of mental illness. Research indicates that comorbid substance use leads to

greater relapse, severity of symptoms and poorer treatment outcomes (Spencer, Castle, & Michie,

2001). However, it must be recognised that many individuals with dual diagnosis simply are not in

a state of readiness to cease their substance use, and to tailor their treatment planning accordingly.

Debate continues to occur around strategies to reduce the harm inherent in these behaviours, and

while successful systems have been implemented (such as needle exchange programs), the ultimate

aim of harm reduction programs is to support an individual into treatment when they are ready to

engage with this process (Mancini & Wyrick-Waugh, 2013).

Harm reduction as a concept remains somewhat abstract to mental health services. However,

with the focus on recovery, it will become necessary for clinicians to accept an individual’s AOD

use and assist in formulating strategies with the individual to minimise the inherent risk in this

activity (Rosemary Ford, 2010). Individuals with a dual diagnosis often have added complications,

in that their use in tandem with the symptoms of mental illness can result in chaotic, unpredictable

behaviour that can leave them vulnerable to exploitation, assault or eviction. The impetus for harm

minimisation is a recognition that AOD use is an inevitable activity in certain individuals, with a

range of associated harms and equally, a range of approaches to respond to these harms (Caulkins &

Reuter, 1997). As a viable adjunct to abstinence, harm reduction needs to be explored and
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 26

implemented for those not contemplating abstinence both to ensure safety in AOD use and

encourage an eventual acceptance of treatment.

Policy Directions

The overarching policy direction in the Victorian mental health system concerning dual

diagnosis is the document Dual diagnosis: Key directions and priorities for service development

(2007). This document recognised the inherent challenges in increasing dual diagnosis presentations

to Victorian mental health services, calling for improved practises, greater research and ultimately

better outcomes for individuals with co-occurring mental illness and substance use disorder. This

document is also primarily the only policy related to dual diagnosis, hence the extensive critique in

this thesis. It also recognised systemic barriers that impeded treatment integration across the

spectrum, at both policy and service level, as well as a continuing provision of what were labelled

“segregated” services: alcohol and other drug treatment services catering for substance use and

mental health services caring for mental illness, with both sectors having little tolerance for

individuals with dual diagnosis.

In each sector, it was also found that services recorded less prevalence of dual diagnosis

than could be expected from population data available at the time, indicative of under-diagnosis and

an inability to respond to dual diagnosis effectively. These concerns resulted in the formulation of

five service development outcomes, being:

1. Dual diagnosis is systematically identified and responded to in a timely, evidence-based manner as core business in both

mental health and alcohol and other drug services.

2. Staff in mental health and alcohol and other drug services are ‘dual diagnosis capable,’ that is, they have the knowledge

and skills necessary to identify and provide integrated assessment, treatment and recovery.

3. Specialist mental health and alcohol and other drug services establish effective partnerships and agreed mechanisms that

support integrated care and collaborative practice.

4. Outcomes and service quality for dual diagnosis clients are monitored and regularly reviewed.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 27

5. Consumers and carers are involved in the planning and evaluation of service responses (p. 23).

In spite of these service development outcomes, some mental health services still struggle

with dual diagnosis and the provision of effective, responsive care to individuals presenting with

co-occurring mental illness and AOD use disorders (Kenneth Minkoff & Cline, 2006). The promise

of linkages between alcohol and other drug and mental health services often no longer exist in any

effective fashion, and the outcomes of clients with dual diagnosis are rarely measured beyond the

implementation of rudimentary outcome measures (Browne, 2006). In this author’s experience, dual

diagnosis capable staff in mental health services are few and far between, with the notion of the

“advanced” practitioner mentioned in the framework very rare indeed. The impetus for undertaking

further study is often non-existent, particularly to the Graduate Diploma level and beyond as would

be expected of an individual to “… [be] able to assess and effectively treat dual diagnosis clients in

an integrated manner within service and practice guidelines,” (p. 18).

The action plan of this report suggested a screening level of 100% of individuals presenting

to the service for drug and alcohol use by June, 2008. At the completion of this document, the

parent health service in question had completed little training in any assessment tool for its

clinicians, leading to a haphazard approach to substance screening. MAPS, the service that is the

focus of this thesis, was not using any screening tool, instead relying on clinicians to ask and record

as a “yes or no” on an intake risk assessment. The problems of this are obvious, not least the

potential for under recognition of co-occurring substance use, leading to individuals having no

consideration of their substance use disorder in treatment and recovery planning and day-to-day

case management needs. These issues were particularly evident during the primary phase of this

research project, the file audit. Examples include an individual being assessed as consuming “5

glasses of wine a night,” yet having a “no” recorded on the substance abuse intake question, even

when this level of alcohol consumption is clearly in excess of Australian Government

recommended guidelines (National Health and Medical Research Council, 2009).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 28

Another service development outcome of this document was the effective measurement of

personal outcomes of clients with dual diagnosis, in addition to regular evaluation of service

responsiveness. Outcome measures are a controversial measure of client “progress” through mental

health treatment systems, often criticised as solely collecting quantitative data to evidence funding

arrangements rather than being of any real measure of an individual’s improvement or decline in

health (Mellsop & Wilson, 2006). As mental health services strive to implement a recovery oriented

approach to the provision of care, the impetus of an individual’s subjective, qualitative account of

their perception of mental health becomes increasingly important (Barker, 2001). To date, the

service that is the focus of this study does not attempt to collect outcome measurements in this

fashion, instead noting drug and alcohol use on the Health of The Nation Outcome Scale (HONOS),

which reduces this to a metric consisting of 0-4 in terms of severity. The simplistic nature of this

measure belies the very complexity of dual diagnosis and neglects gains that may be made in

functioning in spite of alcohol and other drug use (Boden & Moos, 2009).

In addition to the Key Directions document, a recent investigation into inpatient deaths by

the Victorian Government Chief Psychiatrist’s office (2012) recognised the need for comprehensive

alcohol and other drug treatment to be available for individuals with mental ill health. A number of

deaths identified in this study related to overdose of illicit substances, and it was noted by the Panel

performing this investigation that “…In spite of increased awareness and documentation of the

problem [of dual diagnosis], there was still a lack of consideration of the impact of AOD on the

presentation or management of people with severe mental illness during an inpatient episode,” (p.

31). It was felt that the presence of alcohol or other drug use led to a higher potential for individuals

to abscond from inpatient care to seek substances, leading to a recommendation that “… Dual

diagnosis training for multidisciplinary staff in inpatient services include the recognition and

management of alcohol and other drug withdrawal during an admission episode,” including

appropriate referral to specialised treatment (p. 31).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 29

The need for recognition and response to dual diagnosis has recently been identified as a

mental health principle in the Victorian Mental Health Act (2014), declaring that “… persons

receiving mental health services should have their medical and other health needs, including any

alcohol and other drug problems, recognised and responded to,” (p. 20). This declaration provides

an impetus for mental health services to truly accept dual diagnosis as “core business,” as stated in

the Key Directions document. With dual diagnosis becoming enshrined in both recommendations

by the Chief Psychiatrist and the Mental Health Act, the next few years propose to be interesting

times for mental health services in Victoria in regard to the whether implementation of the changes

needed to provide holistic care for individuals with dual diagnosis occurs.

Finally, the Key Directions document indicates a need for consumer and carer involvement

in the planning of service delivery. This thesis aims to consider this notion in its second phase, by

examining the experiences of consumers regarding previous treatment episodes. Unfortunately,

ethical concerns with obtaining consent to interview carers in this process were beyond the scope of

this study, as described further in Chapter Four. Ultimately, it is timely to question whether the Key

Directions document has achieved its stated aims, particularly given the legislative requirement for

dual diagnosis to be recognised in the care of individuals who are consumers of mental health

services. Since 2007, this document has heralded a changing landscape in mental health services,

where dual diagnosis was truly treated as “core business,” rather than an unexpected complication

in the psychiatric treatment of individuals. This thesis intends to examine the effectiveness of this

framework throughout its research phases.

The Differences Between the Mental Health and Alcohol and Other Drugs Sector

Substantial differences exist between the mental health and alcohol and other drug sectors.

These differences are most pronounced in the overarching treatment modalities, as mentioned

earlier in this background chapter. Mental health systems often operate under a custodial nature,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 30

with a high proportion of individuals receiving treatment under the compulsory treatment

provisions mandated in the Victorian Mental Health Act (2014). To contrast the alcohol and other

drug treatment sector, participation by individuals is largely voluntary; an Act exists to provide

mandated treatment, and court orders are often made as part of the judicial system, but engagement

with substance treatment services is largely determined by an individual’s motivation to change

their drug or alcohol use (Gregoire & Burke, 2004).

Both systems also differ in regards to their oversight. Community and religious groups as

well as health services often run drug and alcohol services, however the public mental health

system largely operates under the auspices of the State Government. It should be noted that both

systems have private providers that operate services in a “for profit” arrangement, however the

mainstay of low prevalence mental illness with complex substance use disorder falls to the domain

of the public sector (Rischbieth & Goldney, 1999). This is likely due to the substantive costs

involved in private treatment, often limiting it to those with the financial means or top-level private

health insurance to participate in this system. This situation is true for both mental health and

substance use sectors.

Substantial hindrances for individuals seeking treatment also occur due to this segregation

of sectors. Many individuals with complex mental health problems either find it difficult to engage

in traditional alcohol or drug treatment settings, or the problems implicit in their mental health

make treatment in these settings untenable (P K Staiger et al., 2008). For example, dually diagnosed

individuals may exhibit social anxieties related to positive symptoms of their mental illness, such as

paranoia, making participation in group therapies arduous. The notion of self medication with

alcohol or drugs, evident in much of the research concerning dual diagnosis, may also limit the

intrinsic drive to make change necessary for participation in the majority of substance treatment

settings (Spencer et al., 2001).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 31

The following sections will discuss these differences, which account for contradicting

treatment paradigms, service directions and clientele. There is also differentiation in the clinical

workforce contained in each service. These variations in systems and culture were a stumbling

block to the Victorian Government’s aim to enable cross sectorial collaboration and participation in

the Dual diagnosis: Key directions and priorities for service development (Victorian Government

Department of Human Services, 2007) document. These differences also make the structure and

culture of organisations with differing focus remarkably dissimilar, making interdisciplinary

collaboration difficult (Australian Healthcare Associates, 2011).

Workforce.

The alcohol and other drug treatment workforce differs substantially from the mental health

workforce on a number of levels. Primarily, the level of education required to perform roles in each

service is markedly different. Mental health workers are traditionally identified as professionals,

requiring at minimum Bachelor’s degree tertiary education to enable initial registration to practice.

The predominant workers within the mental health system are nurses, with allied health and medical

professionals forming the remainder of the workforce employed in Victoria (Victorian Government

Department of Health, 2011). In addition, a small proportion of the workforce are Diploma prepared

nurses and allied health assistants supervised by professional staff.

In contrast, the alcohol and other drug sector main workforce largely holds qualifications

provided by Registered Training Organisations or the Technical and Further Education (TAFE)

system (Department of Health, 2011). These qualifications are predominantly of a Certificate IV or

Diploma level, requiring one to two years of study to attain. Criticism of this standard entry

requirement to the drug and alcohol treatment field notes that individuals may lack the research

understanding provided in the university system, making evidence-based practice difficult to attain

(Pidd, Roche, Duraisingam, & Carne, 2012). The advantages of this approach over that of the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 32

mental health sector are largely financial, with average salaries per worker being lower due to this

distinction. This makes service overhead costs lower at the expense of allowing practitioners a true,

research based preparation (Rose, 2008).

Few Australian comprehensive undergraduate alcohol and other drug treatment degree

options exist, with most tertiary offerings at the Graduate Certificate, Graduate Diploma or Masters

level. Most admissions to these programs come from diverse undergraduate specialisations, such as

nursing or psychology (Department of Health, 2011). While not necessarily making alcohol and

other drug workers less competent at their ability to provide therapeutic interactions with their

clients, the lack of a cohesive educational preparation hampers the ability to label this group of

clinicians as a profession. This is evident in the academic journals of alcohol and other drug

societies, where research is often conducted by researchers holding institutional positions, with

studies by clinicians forming a small proportion of those published (Polcin, 2004).

Despite this variation, the alcohol and other drug treatment sector has a number of workers

who have attained the “lived experience,” having recovered from addiction and now working to

help others to achieve this. The efficacy of having clinicians with the lived experience is debated,

however clients often report being able to engage and attain greater rapport with a worker who has

similar experiences to themselves (White & Evans, 2014). The notion of employing individuals

with the lived experience also assists with consumer involvement and empowerment within the

service. Despite this, mental health services tend to minimise paid consumer representation, often

reducing their requirement of employing individuals with lived experience to a single consumer

consultant or peer worker position (McCann, Clark, Baird, & Lu, 2008).

It is apparent that both sectors would benefit from collaborative approaches to their

workforce. Mental health presents as “nurse centric,” with nurses making up the bulk of the clinical
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 33

workforce. It is apparent that nursing has a substantially lower representation in alcohol and other

drug treatment settings (World Health Organisation, 2007). While this finding in itself is not a

concern, it does raise the potential dilemma of educational standards for this sector. Additionally,

the registration requirements inherent in other professions are not required of clinicians working in

the alcohol and other drug sector with Certificate IV or Diploma qualifications.

Mandated versus voluntary care.

Despite the launch of a new Victorian Mental Health Act in 2014, the 1986 Mental Health

Act is largely credited for the policy of deinstitutionalisation and fragmentation of services seen in

Victoria throughout the 1990s (Meadows & Singh, 2003). Now superseded by the 2014 Mental

Health Act, the original 1986 Act laid the foundation for a legislative framework that enabled not

only involuntary treatment in the hospital, but also involuntary treatment in the community. The

legal document allowing this was called a Community Treatment Order. These orders defined

criteria that the individual in question must adhere to in order to prevent readmission to an inpatient

facility, the most common being adherence to the regular administration of a depot antipsychotic

medication or a directive to reside at a specific address.

The 2014 Mental Health Act allows continued use of Community Treatment Orders, albeit

under a different title. The pivotal notion of deinstitutionalisation with enhanced community care

relies heavily on these orders, in order to effect adherence to treatment. Although community

mental health clinics see a large percentage of individuals subject to Community Treatment Orders,

the proportion of older adults case managed by older adult community mental health services under

these orders is significantly lower (Brophy, Reece, & McDermott, 2006).

This methodology of compulsive treatment does not exist in the alcohol and other drug

treatment sector. As mentioned earlier in this thesis, the Severe Substance Dependence Treatment
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 34

Act (Parliament of Victoria, 2010) provides the means for individuals with substance use disorders

to be treated involuntarily, however it is rarely used. It also provides a short timeframe of two

weeks to enable detoxification and medical treatment. After this time, the onus is on the individual

to engage with community based alcohol and other drug treatment services to achieve long-term

recovery; this may clearly be difficult if an individual has consumed alcohol and other drugs to a

point of requiring compulsory treatment for severe illness related to this consumption (Urbanoski,

2010).

The treatment milieu in alcohol and other drug treatment relies on voluntary engagement

and participation in treatment programs, which in turn requires a degree of willingness to change.

Prochaska and DiClemente describe this stage as “action” in their stages of change model (1992).

To reach this stage, an individual has typically had an extended period of “pre-contemplation,”

where use continues with little regard for change, moving to “contemplation.” During

contemplation, individuals often question their ongoing drug use, considering taking action to

reduce or cease their substance use. Often, this process has taken place over a period of time before

an individual decides to engage in action to change their alcohol or drug use (Prochaska,

DiClemente, & Norcross, 1992).

In contrast, mental health services often apply their legislative means to compel treatment

when individuals are at an acute phase of their mental illness. This phase is often hallmarked by

psychosis, mania or depression, where concerns about the individual and their behaviour prompt

clinicians to enforce involuntary treatment orders to ensure the safety of the individual and others.

These orders also allow for rapid treatment and stabilisation, often without the consent of the

individual in question (King & Robinson, 2011). Under these circumstances, treatment engagement

is often difficult both due to the nature of psychosis and the power imbalance inherent in

involuntary treatment in a secure inpatient mental health facility (Floyd, 2013).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 35

It is this jarring contrast between the sectors that is most problematic when applied to

individuals with dual diagnosis. Mental illness may often preclude an individual from ever reaching

the “action” phase of the stages of change model, making alcohol and other drug treatment services

relatively inappropriate or unwilling to utilise their scarce resources on a participant who does not

appear to “want” to make change (Martino, Carroll, Kostas, Perkins, & Rounsaville, 2002). In turn,

mental health services focus on acute treatment, where the motivation for changing alcohol and

other drug use may not necessarily be at the forefront of an individual’s mind. Engaging individuals

in substance use treatment during a time of acute mental illness may be difficult, and is a barrier to

providing this service to individuals (Holt et al., 2007).

Older Wiser Lifestyles: A Reflection

While writing this thesis, I was fortunate to be able to participate in a reciprocal rotation to

an AOD treatment service as described earlier in this chapter. This rotation allowed me to work

with Peninsula Health’s Older Wiser Lifestyles (OWL) service, a community based AOD treatment

service for people aged 60 and over based in the Frankston and Mornington Peninsula area of

Melbourne. This service was developed in response to a recognised growing need in this area,

which is home to a large number of older adults, a growing population due in part to the popularity

of this area as a retirement destination.

During my time working in this program, I was exposed to a number of older adults who

had either been referred or were self-referred for alcohol or substance use disorders. Although the

OWL service was not pitched as a dual diagnosis service, it quickly became evident through

assessing individuals referred to the service that many carried some degree of mental ill health.

Attempts to link these individuals with an older adult mental health service were often met with

resistance, and it was common to be told that these individuals did not fit mental health service
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 36

criteria as AOD use was their primary concern and that they were currently linked with the most

appropriate service.

At one point I was asked to accompany an individual to a psychiatric review at the older

adult mental health service at his request, to both provide support and advocacy. During this review,

I bore witness to a psychiatric registrar advising the individual that his mental health problems

would abate if he abstained from consuming alcohol. This experience clearly demonstrated the wide

gulf between policy regarding dual diagnosis and the understanding held by clinicians. In my

opinion, the individual held a high level of clinical risk and required specialist psychiatric

assessment. Unfortunately, these concerns were dismissed.

The time I spent working in the OWL service gave me an appreciation for the difficulties in

engaging mental health services to provide care for individuals. During my time there, I was

frequently told by community health clinicians of the struggles they had experienced in attempting

to obtain mental health assessment for consumers in their care, or even getting referrals accepted, a

sentiment that has often been echoed at my time working in other mental health services. Prior to

this experience, I felt that mental health services were responsive to referrals and providing care,

however I had effectively lived the experience of Croton’s (2004) barriers to service improvement

through the practice of gatekeeping and restricting access.

I felt that linkages to the older adult mental health service would be beneficial for both

services and recommended that an AOD clinician attend clinical reviews with a view to discuss

dual diagnosis in the mental health setting. Again, this suggestion was met with resistance and an

overarching attitude that AOD was not the concern of the mental health service; an AOD treatment

service existed for a reason, and that should be to address every issue apparent in an older adult

with dual diagnosis. As demonstrated later in this thesis and by research, this is a flawed ideology
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 37

given the presence of a high number of complex issues and medical conditions inherent in this

cohort.

An Overview of the Aged Person's Mental Health System in Victoria

Victoria currently contains 17 aged mental health services, being nine metropolitan and

eight regional sites. These services typically contain an inpatient unit and community mental health

team. This structure is in marked contrast to the 1990s, where mental health services for older

adults were predominantly based in large standalone psychiatric hospitals. The transition to the

current arrangement began in the mid 1990s, where a political paradigm of deinstitutionalisation,

influenced by the practice of least restrictive care as outlined in Victoria’s former 1986 Mental

Health Act, led to a radical transformation of mental health service provision (Meadows & Singh,

2003).

These changes, guided by the Australian National Mental Health Strategy (2003), primarily

involved decommissioning institutionalised care, with a subsequent development of integrated

community and inpatient services in a number of geographically defined catchment areas

(Meadows & Singh, 2003). In describing the transition to a new model of care, Loi and Hassett

(2011) report the formulation of mobile community teams as following the early work of Tom Arie,

a British psychiatrist who advocated for at home assessment of older adults and an ability to

provide community outreach services to those least mobile. Despite this being a noble aim, the

likely motivation of a shift to this model was financial: for example, a comparison of intensive

community treatment to inpatient care by George and Giri (2011) notes that, for the 2007/2008

period, an average inpatient admission cost $15,771. In contrast, intensive community treatment,

involving up to three visits daily in the community, averaged $5563.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 38

These figures illustrate a strong economic impetus for deinstitutionalisation. Meadows and

Singh note that prior to the decommissioning of the Larundel Psychiatric Hospital, Victoria’s

largest, the facility consumed approximately 45% of the State health budget (2003). Today’s model

sees Alfred Health, the parent health service of the Caulfield Hospital MAPS team have 15

inpatient aged psychiatry beds, a far cry from the days prior to mental health reform in Victoria

where entire “back wards” at Willsmere and Plenty hospitals were dedicated to the psychogeriatric

patient cohort (Loi & Hassett, 2011).

Despite the financial benefits of the movement to a predominately community based mental

healthcare model, randomised control trials have demonstrated high degrees of treatment success in

comparison to interactions with a general practitioner alone (Draper, 2000). In spite of this finding,

Draper notes that models of community psychiatric nursing “vary considerably and are often based

on historical resource allocation without evidence of what is most appropriate or effective,” which

is an interesting conclusion given the relentless push to move to this model of care in the wake of

deinstitutionalisation (2000, p. 697).

Clinicians employed to the MAPS service at the time indicated that the promise of suitable

allocation of funds from the sale of Willsmere, a psychiatric hospital based in Kew and sold by the

State government of the time for housing development, did not eventuate. Caseloads were reported

to be unrealistically large, with the bulk of nursing work being the management of older adults

displaced from long-term institutionalised care into a number of local rooming houses in the area

(G. Sumsion & D. Lee (registered nurses), personal communication, January 15, 2014).

In spite of these shortcomings, community treatment of mental illness in older adults has a

number of significant benefits. This modality allows close post-discharge follow up, community

integration and linkage to a number of other services (George & Giri, 2011). It also allows a cost
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 39

effective method for providing case management and crisis assessment for a large number of

individuals at any one time. The multidisciplinary arrangement of community mental health teams

allows a wide variety of specialist clinicians to be involved in the care of an individual, and care

planning is often based around this multidisciplinary approach. Being a mobile service, MAPS is

able to provide an outreach service to older adults in nursing homes, hostels and rooming houses

who may not otherwise be able to access care.

Summary

Dual diagnosis is a complex phenomenon influenced by a number of factors at both a

clinical and policy level. It is also an issue that straddles two treatment camps with distinctly

different workforce cultures, theoretical paradigms and therapeutic goals. Dual diagnosis remains a

challenge to mental health and alcohol and other drug treatment services due to the number of

issues it raises in treatment: greater psychiatric symptomatology, higher relapse profile in both

mental health and substance use, poor treatment engagement and overall less satisfactory treatment

outcomes (Todd, Sellman, & Robertson, 2002).The following chapter provides a cohesive review of

the literature related to dual diagnosis in older adults.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 40

Chapter Three

Literature Review

Introduction

This chapter will examine current literature concerning dual diagnosis in older adults, and

identify deficits in the associated literature. This review uncovered a small number of studies

exploring the criteria of this research project, being dual diagnosis in older adults, however these

studies mostly comprised quantitative population studies, demonstrating a clear lack of qualitative

research exploring individual experiences of older adults with dual diagnosis. Two randomised

control trials were located during literature searches, however these related to treatment

interventions for dual diagnosis in adult (under age 65) populations (Hunt, Siegfried, Morley,

Sitharthan, & Cleary, 2013; James et al., 2004).

This chapter will provide a critical review of published research concerning dual diagnosis

in older adults. The selected literature comprises research studies published in either nursing, allied

health or medical disciplines and also includes grey literature such as government and policy

documents.

Search Strategy

The primary search strategy for this review involved electronic searches of the Scopus,

ProQuest and CINAHL journal databases. Additionally, a number of articles were identified by

manually searching reference lists of seminal articles, and selected from the author’s own reference

library. Searches were initially conducted during late 2013/early 2014 and literature updated during

the life of the project using the same search terms. Conducting an early literature review at the

commencement of the study informed the researcher of contemporary work and identified a clear
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 41

gap in knowledge. The initial search strategy was repeated at the closure of the study prior to

writing the discussion chapter and concluding statements. Research articles were initially sought

rather than opinion or literature review pieces. However, it became apparent during this process that

a number of policy, government and not-for-profit organisational documents contributed to the

discourse of dual diagnosis, and therefore these articles have been included where appropriate.

Key words used in the search included “dual diagnosis,” alone and in combination with the

terms “aged,” “elderly,” and “older person.” Additionally, the phrase “concurrent substance abuse

and mental illness” was included with dual diagnosis using the OR function, as early scanning of

the literature indicated that this is an alternative description of dual diagnosis. This phrase is also

frequently used in research studies and government policy documents. Other key words used in the

search included “substance use/abuse,” “mental illness,” “drug dependence,” “drug abuse,”

“prescription drugs,” “alcohol,” “illicit substances,” “baby boomers,” and “older adults,” were used

in a variety of combinations (see Figure 1 for an illustration of search term combination results).

Despite a large initial number of search results, as indicated in Figure 1, after removing

duplicates and articles not relevant to the topic (such as those using dual diagnosis to describe a

combination of medical conditions), only five articles addressed both mental illness and substance

use disorders (dual diagnosis) in older adults. Two of these articles drew their sample populations

from Veteran’s Affairs data, with the remaining three exploring inpatient and community dwelling

individuals who had been discharged from psychiatric hospitals. This small number of eligible

studies, including the notable absence of any Australian based research, which further emphasised

the need for a Victorian based study exploring the issue at hand.

Although literature concerning both mental illness and substance use disorders in older

adults was scant, a number of studies were identified to inform the background of the study. Studies
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 42

were located that researched substance use disorders as a sole factor in older adults, as well as

historical studies that aid in the understanding of the development of dual diagnosis as policy and

treatment concern. Additionally, appraisal of references revealed a number of frequently cited

pieces of literature that were also critically appraised in the context of this study.

Figure 1. The literature search process.

Limitations Arising from the Literature

Qualitative and quantitative articles that explored the phenomenon of dual diagnosis in older

adults were identified from the search strategy and selected for inclusion. The term “older adults,”

varied widely in the literature, with most considering the age of 50 and older as “aged,” and some

literature lowering the minimum age for older adults to 45 and over. As the health service that is the

focus of this study considers individuals 65 and over as aged, it became necessary to apply a degree
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 43

of caution to those studies considering “older,” particularly given societal conventions and mental

health services structures would describe these individuals 45 and over as middle-aged.

As previously discussed, it was necessary to expand the search strategy due to the relative

dearth of literature exploring strictly older persons with dual diagnosis. A number of studies

completed with adult populations have been included in order to provide a more comprehensive

investigation of the problem of dual diagnosis. Although these populations are quite different in

respect of substances used, morphology of mental illness and social dynamics (for example work

versus retirement), some screening and treatment approaches have been investigated in adult

cohorts only. These treatment approaches sometimes show promising results, making them worthy

of critical examination in this literature review with the caveat that further research in older adults is

required.

The following sections explore themes that have emerged from a comprehensive review of

the literature. These articles were critically appraised for their peer-reviewed status, research

methodology, and their pertinence to the research questions posed in the early stages of this thesis.

Government and organisational papers and studies are also included to define the reference of the

study and demonstrate policy positions that have been adopted in regard to concurrent substance

abuse and mental illness in ageing populations. These studies were located using the Google and

Google Scholar search engines and downloaded directly from the website of the organisation itself.

Conceptualising Dual Diagnosis

This section aims to explore contemporary research identified in the literature search

concerning dual diagnosis in older adults. In addition, it seeks to provide background to the

emergence of the growing concern of dual diagnosis in the field of psychiatry. It also aims to

explore two theoretical models prevalent within the substance treatment research arena, being the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 44

concepts of “maturing out,” and “addiction careers”. As discussed, these models arguably

contribute to the dearth of research concerning older adults with both dual diagnosis and AOD use

disorders.

Current research.

Research regarding dual diagnosis in older adults is scant, with limited data regarding

models of treatment available (Bartels et al., 2006). Much of the research on the prevalence of dual

diagnosis in older adults has focused on Veteran’s Affairs population data, which may not be

applicable to the general population. The majority of published studies are conducted at a

population level, leaving a knowledge gap regarding qualitative experiences of older adults with

dual diagnosis. Additionally, no studies concerning Australian older adults with co-occurring

substance use disorders and mental illness were located during the literature search.

Blixen, McDougall and Suen (1997) conducted a retrospective file audit of 101 community

dwelling adults aged 65 and over, discharged from three psychiatric hospitals in the Southern

United States of America. The authors found 37.6% of the sample had both a mental illness and

substance abuse disorder. In real terms, this figure was 38 individuals, clearly indicating that dual

diagnosis in older adults is a substantial problem for the service in question. Of these individuals,

71% abused alcohol only, and 29% abused both alcohol and other substances. Potentially indicative

of pending challenges with the ageing baby boomer cohort given their advancing age, almost all of

those with alcohol abuse had been consuming alcohol for a period longer than 15 years.

Aside from the finding that individuals with dual diagnosis comprised a sizeable proportion

of the sample, the authors found that the prevalence of depression as a primary diagnosis was by far

highest (71%), with psychosis second (10%). Additionally, it was found that considerably more

individuals with a dual diagnosis were admitted after a failed suicide attempt compared to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 45

individuals with a mental illness diagnosis only. Females also comprised a higher number of those

dually diagnosed (63.2%), and those with a mixed substance use disorder tended to abuse

prescription drugs such as sedatives and anxiolytics. This is in contrast to an adult psychiatric

population who choose to consume illicit substances predominantly, as discussed later in this

chapter.

The researchers recognise the limitations of using file audit as a data source, particularly as

the under-reporting of substance abuse in this population may not be reflected by this methodology

(Badrakalimuthu et al., 2010). Thus, there may actually be a higher number of dually diagnosed

individuals than this research indicates. Kerfoot, Petrakis and Rosenheck (2011) also recognised in

their research that under diagnosis may be a problem due to a reluctance to attach a diagnosis to

older individuals that is viewed as “pejorative.” To further compound this problem, visible

consequences of substance abuse such as falls or confusion are often attributed to medical

comorbidities, and there is an apparent false assumption among clinicians that substance use

disorders rarely occur late in life.

Kerfoot et al.’s research also used a file audit of a national registry of Veteran’s Affairs

clients in the United States of America who were being treated in mental health programs or

accessing inpatient psychiatric services (N=911,725). Despite providing a large sample, the

limitations extend beyond the use of file audit to the use of a veteran’s population, which the

authors describe as predominately male (92.1%). Blixen, McDougall and Suen (1997) previously

found that a large number of dually diagnosed individuals were female, suggesting veteran’s

populations do not accurately reflect the general community.

The authors found a declining dual diagnosis cohort as age progressed. Despite the

percentages appearing to be relatively insignificant, these individuals represented 13,837 of 94,878

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 46

in the 65-74 age group (14.6%), 3,923 of 66,449 in the 75-84 age group (5.9%), and 561 of 20,608

in the 85-94 age group (2.7%). These statistics represent considerable numbers of individuals who

are described as heavy users of psychiatric services. Curiously, these statistics fall well short of the

prevalence of dual diagnosis ascertained in Blixen, McDougall and Suen’s study. Perhaps this is

also a function of the veteran’s population or potentially another concern with using file audit as a

means to discern population data; The authors did also speculate underreporting may be a factor in

their discussion of the results.

Prigerson, Desai and Rosenheck (2001) presented a “cross-sectional survey of a

representative national sample of … mental health program patients,” treated in Veteran’s Affairs

mental health clinics over a two-week period (p. 1). The sample comprised 91,752 United States

nationals. The data collected included clinician reports on outpatient clinical encounters, review of

the patient treatment file and review of inpatient and outpatient care files for all hospital services

provided by Veteran’s Affairs. The authors do not provide a rationale for limiting their data

collection to a two-week period, and indicate that individuals were only considered dually

diagnosed if the clinician reported concurrent diagnoses. This methodology of relying on clinicians

to diagnose individuals as having concurrent substance use disorders and mental illness may also be

flawed, particularly when considering the potential underreporting described in the Kerfoot et al.

(2011) study.

Prigerson et al.’s found that substance use tended to decline as age advanced; Lower rates of

dually diagnosed individuals were found than in Kerfoot et al.’s work, with only 6.9% of

individuals over 65 found to have co-occurring substance use and mental illness. Despite this

finding, dually diagnosed individuals represented an increasing proportion of public mental health

patients, and are shown to be high frequency, long-term users of these services. Additionally, in the

USA, those aged 65 and over are the fastest growing age group, with high rates of chronic illness
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 47

and higher costs of care. Again, although 6.9% seems to be a statistically small number in this

sample, it represents a large number of individuals with complex needs, high fiscal costs of care and

heavy consumption of finite mental health services.

Mears and Spice (1993) specifically chose to explore alcohol use in a cohort of patients

admitted to an elderly acute mental illness unit over a four month period. Seventy-eight patients

were asked to complete a questionnaire within three days of admission. This questionnaire collected

basic demographic and diagnostic data, units of alcohol consumption, evidence of recent stressors

and consequences of heavy drinking, such as falls and blackouts. Medical case notes were also

audited to determine if alcohol history had been explored during the admission process. They found

13% of the population were defined as problem drinkers, with another 6% found to be previously

undiagnosed problem drinkers. In several of the patients there were discrepancies between the

patient’s self-report of alcohol consumption and information from other sources, such as clinical

notes. This finding further supports the notion of under diagnosis in aged populations. Additionally,

the problem drinkers identified in the study were significantly more likely to have changed

accommodation or had been bereaved in the past year, indicating that life stressors may lead to a

late onset of problematic substance abuse in this cohort.

Holroyd and Duryee (1997) used formal diagnostic interviews and the DSM-III-R criteria

for substance abuse to determine prevalence rates of dual diagnosis in 140 patients, aged 60 years

and over, who presented to the University of Virginia Geriatric Psychiatry Outpatient Clinic from

August 1992 to February 1996. The authors postulated that using this method of detection was a

truer determinant of substance abuse than retrospective file audit. Of this cohort, the overall

prevalence of AOD abuse was 20%, with benzodiazepines 11.4%, alcohol 8.6% and narcotics 1.4%.

The level of benzodiazepine dependence demonstrates the complexities of the older adult mental

health cohort in respect to prescription drug abuse, and further reinforces the findings of Levy and
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 48

Andersons’s (2005) qualitative study, where it was found that as substance abusers aged, they

tended to switch to alcohol and tranquillisers as they were both easier to obtain and better tolerated

by ageing bodies.

It is clear that a number of population studies have demonstrated rates of concurrent mental

illness and substance abuse that although statistically speaking are small, in absolute numbers

represent a definite challenge to aged psychiatric services. Given the complex nature of older

mentally ill individuals who abuse alcohol and other drugs, 10 or 20 clients in a service managing

150 individuals at a time represents a real challenge to resources, and may prove costly and time-

consuming to manage and treat effectively (Ringen et al., 2008; Speer, 1990). Given the potential

for under diagnosis of substance abuse in older adults, it is prudent to explore the prevalence of

substance abuse in older adults regardless of mental illness. Studies that attempt to define the

prevalence of AOD use in this population will be discussed further in this chapter.

The evolution of dual diagnosis as treatment concern.

Clinician interest in dual diagnosis as a concept can be traced to the late 1980s, when several

seminal studies from the United States began to explore dual diagnosis as a holistic entity. Prior to

this, mental illness and alcohol or substance use were considered separate concerns. Lehman, Myers

and Corty (1989), in their review and discussion of literature pertaining to the assessment and

classification of individuals with concurrent mental health and substance abuse syndromes,

identified that “The literature seems to support the hypothesis that mental illness and substance

abuse occur together more frequently than chance would predict,” (p. 1119). The authors then

identified the difficulties in categorising and defining dual diagnosis, and the problems with

assessment failing to consider dual diagnosis as a treatment concern in failing to consider the

possibility that individuals are using substances, or misattributing the signs and symptoms of AOD

use to psychiatric sequelae. Given the clinician attention the dual diagnosis consumer cohort was
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 49

experiencing at the time, a call for greater recognition and assessment of dual diagnosis was indeed

a pioneering moment in the evolution of dual diagnosis as treatment concern.

Kofoed, Friedman and Peck (1993) specifically investigated post traumatic stress disorder

and alcoholism in their review of the literature, recognising few published dual diagnosis studies at

the time. During this period, the authors identified a growing amount of literature exploring dual

diagnosis, suggesting that a new approach to treatment was required. This approach required that

clear diagnosis be made, concurrent treatment of both mental ill health and AOD use and control of

symptoms of mental illness. The authors had discovered literature that raised questions regarding

the validity of making psychiatric diagnosis in the setting of concurrent drug or alcohol abuse,

requiring distinct periods of sobriety before diagnosis could be made. Inevitably, this methodology

served to delay treatment of psychiatric symptomatology. The call of the authors for concurrent

assessment and treatment was pioneering at the time given the debate of diagnostics, aetiology and

assessment of dual diagnosis.

Minkoff (1991) argued that an opposing focus existed in mental health and AOD treatment

models in his attempt to outline a comprehensive integrated care system for those with dual

diagnosis. Minkoff recognised the difficulties in integrated treatment, including strain on clinicians

providing services to maintain a level of continuity through multiple treatment episodes in diverse

treatment environments. This point is underscored by the marked differences in aims between

addiction and mental health services, operating under different legislative frameworks and

governing bodies. To confound this issue, both service genres operate under disparate theoretical

frameworks, with mental health services often assertively providing care for individuals, and

addiction services “… [Emphasising] individual responsibility and motivation rather than

disability,” (p. 16). Additionally, there is a distinct dichotomy between abstinence as mandated aim

or ideal goal. Often, psychiatric services demand sobriety, viewing this as a prerequisite to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 50

medication adherence and prevention of relapse of mental illness, whereas addiction services take a

more dynamic view of relapse, often viewing it as an expected setback for individuals overcoming

substance use disorders (Ashton, 2008; Petra K Staiger et al., 2011).

The Australian catalyst for increasing awareness of dual diagnosis was a report titled Not

Welcome Anywhere (McDermott & Pyett, 1993). The aim of this report was to explore the needs of

individuals in the community with a concomitant serious mental illness and substance abuse

disorder and stemmed from a Victorian Community Managed Mental Health Service (VICSERV)

research initiative commenced in 1988. This was in response to concerns from community mental

health workers about the service's lack of skilled workforce and resources to meet the needs of

individuals with dual diagnosis. The project used a mixed methods design, incorporating qualitative

data from individuals identified as having a dual diagnosis, their carers and community agencies. A

quantitative questionnaire was distributed to over 600 mental health, AOD treatment and

homelessness services in Victoria, specifically enquiring as to clinician experiences of co-occurring

mental illness and substance use.

This research found that there were up to 880 individuals with concurrent mental health and

substance abuse problems contacting 300 agencies in Victoria weekly for assistance, with two to

three hundred of these individuals receiving no service whatsoever. The report also found that

clinicians and service providers often felt afraid, overwhelmed, inadequately resourced and

unsupported when confronting clients with dual diagnosis. A number of services were unable to

provide assistance to those with concurrent psychiatric and substance use issues. Numerous reports

of referral to other services predominate, with dually diagnosed individuals frequently referred on

to other service providers, who in turn advised them that they were unable to assist. The report calls

for a more effective response, and the development of a "no wrong door" policy, whereby services
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 51

assessed and treated substance use or assisted clients to access services more appropriate to their

situation, regardless of the presence of co-occurring mental illness (Roberts, 2012).

Roberts (2013) interviewed 19 purposefully sampled “key informants,” being senior

bureaucrats, service providers and consumer researchers with expert knowledge of developments in

dual diagnosis in Victoria during recent decades. Roberts identified four key themes supporting

dual diagnosis as treatment concern. Firstly, individuals with dual diagnosis were more visible. As

discovered in McDermott and Pyett's Not Welcome Anywhere study, this perceived increase was

due to various health departments’ response to complaints about exclusion from services and poor

integration of care and treatment. Additionally, local Victorian research at the time indicated that

almost half the residents in homeless shelters and inexpensive, single room accommodation

(rooming houses) had a current mental disorder and that 10-12% of these individuals had

concurrent substance abuse issues (Hermann et al., 1989, cited in Roberts, 2013, p.328).

Secondly, deinstitutionalisation and a subsequent shift to community care, was a driver for

growth in concern about dual diagnosis. It was speculated by many informants in Roberts’ study

that community services were inadequate to meet the corresponding increase in care requirements

following the closure of state psychiatric hospitals. Roberts describes this as “trans-

institutionalisation,” whereby individuals bypassed treatment and support and instead began

appearing in prisons and homeless accommodation services. Third, there was a greater

differentiation between service treatment philosophies. Similar to McDermott and Pyett’s findings,

fragmentation of services caused a reduction in funding in the early 1990s and the subsequent

adoption of corporate management principles led to narrow funding criteria that encouraged a

separation of treatment responsibilities between AOD treatment and mental health services. The

informants also noted that prior to the 1986 Mental Health Act, mental health facilities were more
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 52

willing to accept clients with dual diagnosis, suggesting AOD use was historically seen as a

frequently expected comorbidity in individuals with mental health problems.

Finally, it was identified that practitioners were drawing attention to increasing AOD

consumption by those with mental ill health. Roberts recognises that the publication of the

Diagnostic and Statistical Manual, 3rd edition (DSM III), provided a "more forensic" screening and

assessment matrix, where comorbidities were more readily identified. The report found that some

informants believed this was an attempt for psychiatric services to “take over” the alcohol and drug

treatment system, however it became apparent that a resistance to enhanced multidisciplinary work

between addictions and mental health clinicians failed, with the Roberts (2013) speculating that this

was a challenge to the psychiatrist's authority and desire to remain the “gatekeepers” of acute bed

access.

Although deinstitutionalisation did not solely cause dual diagnosis to arise as a treatment

concern, it is clear that a number of factors in Victoria's health service history at this time increased

interest in the problem amongst clinicians. The fiscal circumstances of the time resulted in a

significant reduction of funds available to services. Additionally, mental health services were

relocated within general hospitals. These factors led to a number of individuals being displaced into

the community. This group, often living in apparent poverty and lodged in supported

accommodation or rooming houses, would become a ready market for those selling illicit

substances (Goodman et al., 2013; Office of the Public Advocate, 2013). It is reasonable to

conclude that, without the relative isolation of psychiatric hospitals and the nature of their constant

staffing, individuals with mental ill health simply could not access services when required and

instead used a variety of substances to cope.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 53

When considering services for older adults, it becomes readily apparent that a process of

concern regarding dual diagnosis has not yet occurred, at least not to the extent evident in

individuals under 65 years of age. Whether this lack of concern is related to a notion that older

adults simply do not use or abuse alcohol or other drugs, or a reluctance to ascribe substance use to

older individuals, it is clear that a shift in awareness is required (Crome, Crome, & Rao, 2011). A

theory commonly explored in alcohol and other drug treatment research is that of “maturing out,”

whereby it is assumed that individuals cease substance use when social circumstances become

supportive to this cessation. This theory is discussed in detail in the next section of this literature

review.

The apparent failure of the maturing out hypothesis.

In 1962, Winick hypothesised that addiction “… may be a self-limiting process for perhaps

two-thirds of addicts,” (p.7). Winick’s concept of “maturing out” was based on the notion that

individuals became addicted in their teens or early twenties in order to avoid or postpone the

problems of adulthood. Winick then went on to suppose that substance use ceased as these

“vocational decisions and social pressures,” became less pressing (p. 6). Thus, the concept of

maturing out of substance addiction has been widely adapted amongst drug and alcohol treatment

services and academics alike, often forming a basis for the modern natural recovery movement,

despite limited studies testing this hypothesis (Anderson & Levy, 2003; Granfield & Cloud, 1996;

Waldorf, 1983).

In relation to individuals with dual diagnosis, Winick’s hypothesis becomes less applicable.

The original study of 7,234 individuals did not assess the effects of mental ill health on substance

use. Additionally, the sample was based on Federal Bureau of Narcotics data. Winick justified this

sampling methodology by stating “Experience has shown that it is almost impossible for a regular

user of narcotics to avoid coming to the attention of the authorities within a period of about two
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 54

years, so that addicts known to the Federal Bureau of Narcotics represent as complete a picture of

the addict population as it is possible to obtain at this time,” (p. 1). Arguably, Winick had

performed a study of criminal substance abusers, thus ignoring the notion of the ageing “invisible

addict,” as postulated by Crome, Dar, Janikiewicz, Rao and Trbuck (2011).

Despite being a statistically small number (3.8% of the total sample), the Bureau of

Narcotics figures used by Winick included 273 individuals becoming “inactive” users in the 60 plus

age bracket, with inactivity being described as no contact with the Bureau for a period of five years.

This finding itself tends to raise the question of whether the individuals really did cease substance

use, or as found by Levy and Anderson during qualitative interviews, “older [drug] injectors tended

to substitute alcohol and barbiturates for illicit drugs when the latter were unavailable … or the

physical effects … were too harsh for an aging body to handle,” (2005, p. 250).

Winick’s work failed to recognise this phenomenon, with sampling excluding those using

prescribed drugs, including barbiturates and opiates, under medical supervision. Hence, it is

reasonable to conclude maturing out may not have occurred, with individuals switching to

substances that are more convenient to obtain. This may go some way to explain the statistically

smaller number of older substance users. Admittedly, Winick’s research sought to discover usage

“careers” in illicit drug users, which at the time and due to the geographic locale of the study

represented primarily opiate addiction. The maturing out hypothesis has been explored in regard to

alcohol consumption but has not been supported in multinational studies (Wilsnack, Wilsnack,

Kristjanson, Vogeltanz-Holm, & Gmel, 2009).

In response to Winick’s research, Ball and Snarr (1969) sought to test the maturation

hypothesis using a follow-up study of 242 former addict patients from the Lexington Hospital,

Puerto Rico, during 1962-1964. Ball and Snarr used a wide range of data sources, including
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 55

hospital, police and prison records in both Puerto Rico and the United States, Federal Bureau of

Investigations arrest records, Bureau of Narcotics records, interviews with relatives and friends,

interviews of the individual, analysis of urine drug specimens and other sources, examples of which

identified included newspaper accounts and death certificates.

The wide range of sources the authors used to explore the trajectory of addiction careers

would allow a more thorough investigation, rather than relying on the notion that drug addiction

leads to criminal conviction that Winick used to underpin his work. Consequently, Ball and Snarr

found no evidence “… to support the interpretation that abstinence increases either with years of

drug use or the ageing process itself,” (p. 2). Interestingly, however, several authors contend that

this study lends support to the maturation hypothesis (Anglin, Brecht, Woodward, & Bonett, 1986;

Sobell, Ellingstad, & Sobell, 2000). This is a curious finding, given the research found 67% of those

studied were either continuing to use heroin or incarcerated at the time of follow-up, indicating a

substantial deviation from Winick’s proposition that “two-thirds” of users matured out of substance

use. It would appear that the wide range of data used to produce this result describes a more

thorough account of substance use throughout the lifespan.

Ball and Snarr supported Winick’s hypothesis of addiction partnering with criminal

behaviour. The authors found that addiction increased the probability of arrest fivefold in their

sample. Despite finding that 90% of those “cured” did not come into contact with the authorities

during abstinence, Ball and Snarr could not confirm Winick’s supposition that opiate users mature

out of criminal lifestyles, with the trend towards greater “social disability” as the years progressed.

Ultimately, the authors identified two patterns in the careers of opiate addiction, with the first being

increasing immersion in a criminal lifestyle as opiate dependence progressed throughout adult

years, and the second being a termination of a drug-centred lifestyle and re-establishment of a
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 56

“legitimate role” in society. Ball and Snarr found one-third of their sample assuming the second

pattern, as opposed to Winick’s two-thirds.

In 1973, Snow also sought to replicate and extend Winick’s maturing out hypothesis. Snow

recruited all addicts reported to a central register in New York City. A total sample of 3655

individuals was obtained. Snow considered this sample to be a closer approximation of Winick’s

study than others. Snow separated “inactive” cases, who became this way through death,

incarceration, lack of information, or “questionable evidence of addiction,” (p. 923). Of interest to

the study of dual diagnosis is the finding that 102 of a total of 741 inactive cases in the sample were

found to be this way through confinement in psychiatric institutions, from a period of nine days to

three years, underscoring a definite cohort with co-occurring substance abuse and mental illness

even in this early work.

Snow found an appreciably smaller percentage of individuals who had matured out of

substance abuse at 23%, considerably less than Winick’s 65%. Although Snow pondered

explanations for this discrepancy such as a differing situation in New York City due to a later time

period being studied and the elimination of deceased individuals from the sample, it was concluded

that the complexities of maturing out as a phenomenon were generally more complex than Winick

had regarded them to be. This point was demonstrated by the large number of subgroups discovered

in the sample, with widely varying addiction and cessation rates. Snow attributed this to differing

socioeconomic circumstances providing more opportunity for individuals to cease substance use,

and conversely, poverty leading to ongoing addiction. As Snow concluded, “… it may be that only

some of these inactive persons have in reality matured out… or that none have. But it is undeniably

true that they have all achieved a state of anonymity that needs to be accounted for,” (p. 936). This

statement seems to echo the notion of the “invisible addict,” (Crome et al., 2011).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 57

Capel and Peppers (1978) sought to explore the concept of “the ageing addict.” At the time,

the general consensus in addiction medicine was that opiate use decreased sharply after the age of

45. This notion was fostered by Winick’s maturing out hypothesis. The authors noted that opiate

addiction was previously an affliction of middle and upper class women, with an average age in the

forties. The demographic in the 1960s appeared to change, with opiate addicts tending to be

predominately young, male and black. According to Capel and Peppers, this resulted in concern

being directed at younger members of society, neglecting drug abuse among older individuals.

Capel and Peppers study utilised 1969 data obtained from substance abusers enrolled in

methadone maintenance clinics in New Orleans, focussing on the change of age distribution since

1969, and what the authors describe as the “staying power” of individuals enrolled in the program

since that time. They found that although opiate addiction occurred most commonly in people under

37, there was a virtual doubling of the 45-59 group and 60 plus groups, indicating an overall ageing

trend. As predicted by Capel and Peppers, individuals in these older age groups were expected to be

in their late fifties or sixties by the mid 1980s, demonstrating a definite aged cohort undergoing

methadone maintenance treatment. The authors, in their conclusion, stated “To a greater extent than

younger age groups, we find some evidence of what Winick called the “maturing out process” that

occurs naturally, but it is equally clear that this is not the case for the majority of those now

addicted and in the older age brackets,” (p. 399).

The work of Beynon, McVeigh and Roe (2007) explored the English National Drug

Treatment Monitoring System, consisting of the records of 26,415 individuals who contacted

treatment services between 1997 and 2005. The researchers found that although the majority of

drug users in treatment were aged 49 years or younger, there was a significant increase in the 50-74

age bracket. A median age increase of eight years in average ages of individuals in treatment was

also noted during this time, as well as and increase in drug users in contact with syringe exchange
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 58

programs in the 50-74 age group, from four in 1992 to seventy-four in 2004. These findings lend

contemporary support to Capel and Peppers prediction of an ageing cohort of individuals with

substance use disorders.

Levy and Anderson’s (2005) qualitative study used a convenience sample of 40 older

(between the ages of 50 and 68) intravenous drug users to explore the concept of a drug using

“career” throughout the lifespan. These individuals all began drug use in their teens or twenties and

continued to use drugs spanning prolonged periods of 25 or more years, further raising doubt about

the maturing out hypothesis. A distinct feature of the research was the indication that older

substance users tended to substitute other substances, namely alcohol and prescription medications,

for illicit drugs when availability or tolerance for an ageing body became problematic. This finding

cast further doubt on Winick’s maturing out hypothesis by adding a variable that was not explored

in Winick’s initial study. Rather than stopping illicit drug use, older substance users may simply

switch to more convenient substances when circumstances force the choice to be made.

To summarise, although a proportion of substance users may mature out per Winick’s

hypothesis, there is a significant cohort that appear to continue their substance use unabated. As

indicated by subsequent research, there appears to be a trend whereby older age groups of those

dependent on substances have increased, either not maturing out of their substance abuse or

commencing addiction careers later in life. The maturing out hypothesis may have been a

convenient demonstration for the perceived insignificance of an aged substance abusing cohort,

however upon further investigation it becomes clear that a number of variables that were omitted

from Winick’s work may contribute to a growing number of older adults dependent on substances.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 59

The "lifetime" user.

Defining addiction as a career is common within injecting drug use research, with the notion

of the “lifetime” user expressed as an individual who commences injecting substances at a young

age and modifies their use throughout the lifespan (Lay, King, & Rangel, 2008). According to the

Australian Injecting and Illicit Drug Users League, “There is also recognition, that people’s

engagement in drug use is often fluid, and that people frequently move in and out of active drug use

over long periods of time even if their ultimate goal is to quit using,” (2012 p. 6). This notion of the

lifetime drug user is at odds with the maturing out hypothesis described by Winick, indicating that a

group of those initiating drug use in their youth will continue using substances up until older age.

Although the research surrounding addiction careers does not consider dual diagnosis, it is pertinent

to explore as it provides a potential explanation for the rejection of the maturing out hypothesis, and

allows exploration of the social, health and legal costs of the maintenance of a long-term substance

use disorder.

The concept of users adapting to enable ongoing use was recognised by Capel, Goldsmith,

Waddell and Stewart (1972), causing the authors to announce that “[the] maturational hypothesis

has become suspect,” (p. 102). By interviewing 38 individuals identified to the researchers through

leads participating in a New Orleans methadone maintenance program, the research was able to

explore active users, in contrast to typical research of the time which recruited through law

enforcement or treatment program registers. The 38 individuals sampled were all male, with a mean

age of 58.9 and a mean drug use career of 35.4 years. The majority of the group were using

pharmaceutical hydromorphone, with a number using heroin, morphine or codeine. Participants

noted their primary reasons for using hydromorphone as cost, being cheaper than heroin, and purity

of dose.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 60

Challenging the notion of the narcotic addict as hopeless, criminal and antisocial, 19 of the

subjects were employed in full time employment, and five part time. However, it was noted that the

vast majority of males were isolated and living alone, with only one married and living with his

spouse. The authors also found that the modality of treating addiction as a legal problem, replete

with long jail sentences at the time encouraged “… self-protective camouflage by the addict who

therefore becomes hidden and shut off from influences that might lead to his maturing-out of the

addiction,” (p. 105). It was also noted that the only options for treatment were either methadone

maintenance or total abstinence, which appeared to be of little interest to this age group. This

situation, with the addition a limited number of alternatives to methadone, stands largely to this day

(Garcia-Portilla, Bobes-Bascaran, Bascaran, Saiz, & Bobes, 2014).

Although concerning adults with a lower mean age (43) than most other studies exploring

this group, Williams Boeri, Sterk and Elifson’s (2008) qualitative analysis of 29 heroin users sought

to explore the differences between what are termed “maturing in” users (those commencing heroin

use before the age of 30), and late-onset users (who commenced use in their 30s or older). A

number of core differences are described between these categorisations, particularly regarding

adaptive behaviours of the maturing in users. These behaviours tended to develop in order to allow

individuals to continue substance use while attempting to maintain mainstream life roles, including

the ability to manage withdrawal by titrating their use in order to remain a sense of control over

their drug use. In contrast, the late-onset users surveyed frequently described their use spiralling out

of control, causing detrimental impact to their familial relationships and subsequent role

functioning.

Despite this notion of controlled use allowing maturing in individuals to attempt to maintain

normalcy within dual roles, Darke et al (2009) found that harms associated with injecting heroin use

were strongly correlated to length of career. This longitudinal cohort study recruited 619 individuals
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 61

from 19 AOD treatment services in Sydney, along with a number of active users from needle and

syringe programs as controls. Baseline interviews were conducted, combined with data from the

Australian Treatment Outcomes Study, with interviews repeated at 3, 12, 24 and 36 months.

Despite this study being conducted with a younger cohort (mean age 29.3 years, with an age

range of 18-56 years), it surveyed a number of individuals with heroin careers over 15 years. Of this

group, it was discerned that cumulative exposure to overdose caused a number of health problems,

including cognitive damage. In addition, the older users surveyed in the study showed no evidence

of reducing their use, with no reduction in risk taking behaviour observed. The authors postulate

that this may be an explanation as to older users being the chief age profile represented in heroin

fatalities.

A similar study conducted by Grella and Lovinger (2011) in California interviewed 914

individuals participating in methadone maintenance programs during 1978-1981. Follow up

interviews were conducted from 2005 to 2009 with 428 subjects, with 414 original subjects

deceased and the remainder being either incarcerated or lost to follow up. The average age at follow

up was 58.3 years for males (SD ± 4.9), and 55.0 years for females (SD ± 4.1). A model for

trajectories of use over time was developed, finding that two-fifths of the sample had ceased using

heroin 10-20 years after initial age of first use, with a quarter (25.5%) continuing their use at

follow-up. The authors also found that half of those noted to cease heroin use most rapidly

increased their use of other drugs, particularly amphetamine, over this time.

Anderson and Levy’s (2003) qualitative study of 40 intravenous drug users between the ages

of 50 and 68 found participants reporting a number of chronic health conditions they attributed to

long careers of drug use. The participants, drawn from 1066 participating in a wider project

exploring HIV and drug use in Chicago, were selected by convenience sampling to discuss the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 62

impact of drug use as they aged. Participants reported wide ranging health issues, from

complications of blood borne viruses such as hepatitis and HIV, to problems associated with

injecting, such as collapsed veins, ulcers and scarring, in addition to health complications arising

from the hazards associated with drug use, such as complications arising from previous gunshot

wounds. A number also identified mental health problems as a result of participating in long term

substance use.

Echoing other authors presented in this section, Anderson and Levy also found participants

reporting competing dual roles throughout the term of their substance use, with a common theme

being a belief that drug use occurred outside family life. Considered necessary to enable continued

use, this notion of operating in two worlds further marginalised participants in the study.

Participants reported often losing family support in the process of becoming marginalised in

conventional roles as well as ageing in a drug scene that was noted to be transforming, with

violence and predatory behaviour becoming commonplace. As the authors note, “Rather than

having ‘matured out’ of the life, these older survivors of an earlier era remained active but hidden,”

with their ability to operate within drug trading circles reported to be curbed by their advancing age,

and chronicity of their medical and psychological conditions (p. 98).

Follow up research by Levy and Anderson (2005) used the same pool of participants, with

the findings underpinning those mentioned in the beginning of this section: many had used illicit

drugs since their teens or early adulthood, with addiction careers spanning 25 or more years, with

brief periods of quitting substance use over this time reported. Throughout their substance use

careers, the participants noted that they still spent much of their time seeking illicit substances,

however competition for this time came from the necessity to manage the symptoms of chronic

conditions attained as a result of drug use.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 63

Participants described a fear of hospitalisation that often discouraged them from seeking

medical help, as it effectively separated them from their drug supply. This finding in itself is

concerning, particularly if a similar attitude existed among individuals with dual diagnosis, forcing

a reluctance to seek help when psychiatric conditions exacerbated. It was also found to prevent

older adults seeking help from substance use treatment services. Social isolation, found in older

substance users as their drug using friends either cease use or succumb to their medical conditions

or overdose, was also noted in the participant’s responses. Combined with the possibility of losing

connection with families, and a reluctance to seek help, social isolation may contribute not only

further risk to complex situations but make adequate assessment in older adults difficult.

The notion of addiction careers is in direct contrast to the maturing out hypothesis and

provides an opportunity to account for those who were outside the bulk of those ceasing substances

in Winick’s research (1962). No study of substance use careers in older adults with co-occurring

mental illness was located in the process of this literature review, however the concept of a career

provides rich, individual data that may help to explain the course that an older adult’s life has taken

when presenting to mental health services with dual diagnosis. As evidenced by the literature

presented here, long-term substance use has significant effects on the health and social welfare of

individuals. The lack of studies concerning lifetime trajectories of mental illness and substance

abuse in older adults provides further impetus for the research methodologies of this thesis, in order

to adequately illustrate the phenomenon of dual diagnosis in older adults.

The Extent of the Problem

This section seeks to define the prevalence of substance abuse in older adults. A large

proportion of the literature concerning older adults’ views substance abuse in isolation, with passing

consideration to mental illness. Given the definite lack of dual diagnosis research in older adults,

examining this research was considered pivotal in defining the extent of the issue. This section will
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 64

also identify costs of care of dual diagnosis in older adults and compare the adult mental health

cohort with older adult mental health consumers. It will also examine the potential consequences of

untreated dual diagnosis in older adults.

Prevalence of AOD use in the aged cohort.

A number of studies exist exploring the prevalence and issues of substance abuse in a

generalised older population (Blazer & Wu, 2009a, 2009b; Han, Gfroerer, Colliver, & Penne, 2009;

Simoni-Wastila & Yang, 2006). These studies do not specifically explore dually diagnosed

individuals, in that they do not seek a population with a comorbid mental illness diagnosis to draw

their sample from. Given the potential of under diagnosis of both substance abuse and mental

illness in older adults, and the difficulties of involving individuals with severe psychosis in

population studies due to both study recruitment and ethical considerations, a review of the

literature pertaining to substance abuse alone is warranted in order to determine a true prevalence of

substance abuse disorders in older adults (Hartz et al., 2014; Salmon & Forester, 2012).

Moos, Schutte, Brennan and Moos (2009) conducted a 20-year longitudinal study on a

sample of 1884 community residents 55-65 years old at baseline from Western USA to determine

alcohol consumption and drinking trajectory in later life. The individuals comprising the sample

were born between 1921 and 1933, had consumed alcohol within the past year and had outpatient

contact with a healthcare facility in the past three years at baseline. They were then contacted at 10

and 20-year time points. Of the 915 individuals still living, 719 completed the twenty-year follow

up, with the remainder being unable to participate due to ill health or refusal to participate.

The authors used a combination of mail and telephone survey to determine alcohol

consumption and problem drinking patterns. The 12 item Drinking Problems Index was used, an

instrument with high internal consistency and predictive validity (Cronbach’s alpha 0.94). At the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 65

twenty-year follow up, when participants ages ranged from 75-85, a total of 15% of women and

30% of men reported their alcohol consumption as 3 or more drinks per day or 14 or more drinks

per week. Additionally, 8% of women and 22% of men reported consuming more than two drinks

per day or seven per week and subjectively reported this consumption as being problematic.

Although the authors found a decline in alcohol consumption as age advanced, more than half of the

older adults surveyed consumed alcohol in excess of recommended guidelines. Accordingly, 21%

of women and 34% of men in the sample described problems related to their alcohol consumption.

This highlights a sizeable cohort of older adults who consume problematic quantities of alcohol,

despite longitudinal findings that consumption decreased within the population as age advanced.

Blazer and Wu (2009a) further explored levels of problematic alcohol consumption in older

adults. They examined the public files of the 2005-2006 US National Survey on Drug Use and

Health to determine the prevalence of “at-risk” (more four drinks per day or 14 per week) and binge

(more than five drinks on the one occasion) drinking among middle aged and elderly adults. Of this

data, the sample was limited to 10,953 respondents who were 50 years of age or older. Of note is

that individuals excluded from the sample comprised those in prisons, nursing homes, mental

institutions and homeless individuals, excluding a large number of individuals with mental ill health

as discussed previously in this literature review.

In terms of binge drinking, men showed a higher prevalence (20%) compared to women

(6%), and at-risk drinking (17% versus 11%). The study found that binge and at-risk drinking is

associated with illicit drug use in males and non-medical use of prescription drugs in females.

Additionally, binge drinking was found to be associated with higher income and separation, divorce

or being widowed in men. The implications for a treatment service that operates within a diverse

catchment area (as described in Chapter 2) are numerous, particularly given a large proportion of

individuals case managed by MAPS live alone, and a substantial geographic area of the MAPS
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 66

catchment is in the higher income suburbs of Melbourne. Blazer and Wu also highlight the poor

value of brief screening tools such as the CAGE in identifying binge drinking. Given the variable

nature of self-report as many authors have noted, accurate assessment of binge and at-risk drinking

may prove difficult.

Seeking to explore trends in admission patterns of older adults to publicly funded substance

abuse treatment services, Ardnt, Clayton and Schultz (2011) audited yearly data sets from 1998 to

2008 of all admissions to treatment facilities in the United States. Treatment service staff also

identified, via interview on admission, basic demographic information and the primary substance

leading to admission. Of a total sample of 7,446,785 for all years of the data set, 258,542 were aged

55 years or older. The authors chose to use adults aged 30-54 as a comparison group (n=3,547,733).

In contrast to other studies in this review, Arndt, Clayton and Schultz found a “steadily growing

proportion of older adult admissions … among all first admissions [to AOD treatment services],”

(p. 706). In 1998, 2.86% of admissions were older adults, increasing to 4.42% in 2008. Confirming

the findings of other researchers, the authors found alcohol to be by and large the primary substance

of choice among this cohort. However, they also found a dramatic increase in admissions for heroin

use, and, as would be expected in a study completed in the United States, an increase in cocaine

use, which was also the second most abused substance after alcohol.

This study also found the number of older adults entering substance abuse treatment is

increasing. The authors postulate that their findings are at odds with the notion that a relatively

insignificant percentage of heroin users live to old age. Additionally, the older adults included in the

sample demonstrated a prolonged exposure to substances during their lifetime, in what the authors

term “successful” users, who represent an unknown population in terms of size, cognition, and

medical and psychiatric comorbidities.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 67

Further supporting the notion of growth of substance use in older adults, Fahmy, Hatch,

Hotopf and Stewart (2012) analysed data from two surveys in England: the 2007 National Survey of

Psychiatric Morbidity and the 2008-2010 South East London Community Health survey. This

analysis found a tenfold increase in recent cannabis use in the 50-64 cohort from 1993 to 2007, and

a twofold increase in individuals 65-74 from 2000 to 2007. The growth of cannabis use in this

population is illuminating, as many other studies mention cannabis in passing rather than as a

problematic substance (Patterson & Jeste, 1999; Shah & Fountain, 2008). Although the authors

advise that the prevalence, in percentage terms, is low, they do concede that this translates to high

numbers of substance users at a service level and call for research into treatment frameworks that

are sensitive to the needs of older adults.

Although not investigating the general population, Cummings, Cooper and Johnson’s (2013)

examination of older adults residing in public housing and alcohol use provides a sample more

relevant to a cohort specific to the MAPS service, as identified in the background chapter. The

authors administered health surveys to residents of two public housing buildings (n=338), with 187

completing the survey. Almost two thirds (60.1%) of the sample were aged 65 and over, with

30.5% of the older resident cohort reporting substance abuse problems. Measuring problem

drinking using defined guidelines, a high percentage of binge drinkers (21% of all residents) was

discovered. The authors suggest two potential reasons for this finding: binge drinking being used as

a coping mechanism during periods of acute stress and restricted income limiting regular access to

alcohol. The implications of this finding are clear, as the study also found that public housing

residents rarely disclosed their problematic substance abuse to health professionals, and none of the

sample classified as problem drinkers receiving specific substance abuse treatment in the 30 days

prior to their interview.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 68

Although the aforementioned literature does not specifically seek to describe populations

where individuals experience co-occurring mental illness and substance abuse, it provides

illumination of the prevalence of substance use in an ageing population. As found by Cummings,

Cooper and Johnson (2013), individuals do not necessarily disclose their substance use to health

professionals, making a true population prevalence difficult to accurately identify. In addition, a

number of the reviewed studies deduce an increase in substance use in older adults. Combined with

the notion of the “successful user,” (Arndt et al., 2011) these factors indicate potentially a large

number of undiagnosed substance use disorders within the older adult community.

Costs of care.

The costs of care for older people with dual diagnosis are difficult to quantify. Primarily,

Australian data collected regarding costs of dual diagnosis to health services and systems does not

attribute costs specifically to the 65 and over age group, who comprising older adult mental health

service users in Victoria. Additionally, no research was found during literature searches exploring

financial costs of treating older adults with dual diagnosis in Australia. Despite this, Government

spending on mental health services nationwide during 2010-11 was reported at $6.9 billion, and

represented an average annual increase of 6.3% from the previous measurement conducted in 2006-

2007 (Australian Institute of Health and Welfare, 2012).

According to a Medibank Health Solutions report (2013), as a total proportion of health

expenditure, mental health ranks highly. This report estimated direct spending on mental health

services at $28.6 billion per year, a markedly higher figure than provided by the Australian Institute

of Health and Welfare. This may be explained by the inclusion of what are termed as “non-health”

expenditures, such as housing, carer and justice services, and income support payments. To

determine these costs on an individual level, Fitzgerald et al. (2007) examined the records of

payment and activity systems in medical records for 347 individuals with a diagnosis of
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 69

schizophrenia treated at a metropolitan Melbourne mental health service. Analysis of the fiscal data

discerned a societal cost of $32,160 in the first year of treatment, $27,190 and $29,181 in the

second and third years respectively. The research also noted that 39% of individuals included in the

study consumed the vast majority of health service resources, which further serves to indicate the

intensive nature of both chronicity and complexity in respect of finite resources.

As this study did not explore an aged population, it assumes lost taxation revenue in its

calculations. Although a substantive figure, a similar figure could be achieved by substituting the

cost of Government subsidised aged care services, both residential and community, provided to a

number of individuals over the age of 65 (Australian Government Department of Health and

Ageing, 2011). This study did not assume costs related to individuals with co-occurring substance

abuse, with studies finding that costs of care for dual diagnosis being higher due to medical

comorbidities, suicide attempts and poorer role functioning and emotional health, as well as an

increase in psychiatric symptomatology (Benaiges, Prat, & Adan, 2012; Ringen et al., 2008).

Early research into the cost of treating individuals with dual diagnosis conducted by Hoff

and Rosenheck (1999) found the mean yearly individual cost 31% higher than treating individuals

without comorbid substance use disorders. To arrive at this conclusion, the authors compared two

groups of patients from a Veteran’s Affairs substance abuse treatment program (n=12,607),

comprising 3,069 dual diagnosed and 9,538 non-dually diagnosed. Four sources of data were

scrutinised, being clinician completed data sheets for each patient’s clinical encounter, patient

treatment files for inpatients (4,845 of the total sample), longitudinal files that spanned both

inpatient and outpatient settings, and Veteran’s Affairs cost accounts used to estimate costs for

Veteran’s Affairs health service program delivery. Individuals were followed for six years to

determine patterns and costs of health service utilisation over time.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 70

Two patterns were discerned from investigation of the data, the first being that the dual

diagnosis patients in the sample had persistently and substantially higher costs of care, chiefly due

to a higher utilisation of outpatient medical and surgical care in the first three years of follow up,

and higher costs of substance abuse treatment in the final three years of follow up. Additionally,

both groups showed decreased costs of care over time, with the dual diagnosis group’s costs

decreasing more rapidly. However, despite these costs decreasing, they remained substantially

higher than the cost of care for those without dual diagnosis at the end of the six year follow up

period.

McCrone et al. (2000) also sought to determine the service use and costs of dually

diagnosed individuals in London, using multiple regression analysis of two groups of individuals 18

to 65 years old who had contact with a mental health service over a six month period. Prospective

patients were then interviewed using screening questionnaires in order to identify cases of dual

diagnosis. The number of cases interviewed for inclusion in the study was 101, of which 29% had a

dual diagnosis. The mean cost for dual diagnosis patients was found to be significantly greater, and

during the six month period, was averaged to a financial value of 1362 Pounds Sterling greater than

non-dual diagnosis patients. The authors note that a limitation of their study was the exclusion of

both personal and family financial cost, which, they argue, would add an even greater burden.

At a service level, the notion of individuals with dual diagnosis being heavy users of finite

resources is illustrated in Minassian, Vilke and Wilson’s (2013) study of frequent users of

emergency departments. By conducting a retrospective review of all ED visit medical records

during 2008 (39,249 patients), the authors found that “Patients with both a psychiatric history and

alcohol abuse history had, on average, the highest number of visits per year,” (p. 521). Of all visits

made to the emergency department, 28% were made by those termed frequent visitors, presenting
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 71

four or more times in a twelve-month period. Frequent visitors were also found to be older in age

than non-frequent visitors to the emergency department.

The authors make mention of dual diagnosis individuals in their discussion, noting that their

study was the first to report that psychiatric complaints combined with alcohol use were heavy users

of emergency departments, averaging six visits per individual. A comparison is made to individuals

with either a psychiatric condition or alcohol use disorder alone averaging two visits. This

sentiment is echoed in Hendrie et al’s (2013) comparative study of 339 older (65 years and over)

individuals with a mental illness diagnosis attending a major health service in Indiana, USA.

Medical records were reviewed and results compared with a comparison group of 533 individuals

without a diagnosis of mental illness or dementia, using descriptive statistics (t-test and chi square).

This analysis discerned that the cohort of patients with mental illness had significantly

higher rates of falls, more visits to the emergency department and longer hospitalisations than the

non-mentally ill group. It was also found in the mentally ill group that substance and alcohol use

disorders occurred more frequently. Although not reflected in the research, with similar levels of

medical comorbidity found between the control and mentally ill groups, the authors speculated that

this may be a function of under identification by hospital physicians. This, according to the authors,

may be occurring due to poor information being available from the individual and caregivers, and

“… these patients are difficult to evaluate,” (p. 1273).

Despite the availability of specific research to confirm the cost of treating older adults with

dual diagnosis, it is apparent that the findings of the studies explored here demonstrate the

complexity of these presentations and the potential for older adults with dual diagnosis to compete

heavily for finite resources within health services. Although difficult to quantify, this added expense

appears to take the form of extensive emergency department presentations and increased length of
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 72

stay, both factors that have been identified was contributing to the overall cost of providing

healthcare (Department of Health, 2013a). It is clear that the provision of a comprehensive

community treatment program for older adults with dual diagnosis is imperative to providing the

level of support these complex individuals require, with the potential for reducing the demand for

services from these individuals.

Contrasting the aged cohort with the adult psychiatric population.

A large number of studies have been conducted on the Australian adult (age 18-64) cohort in

regard to dual diagnosis (Croton, 2005; Ogloff et al., 2004; P K Staiger et al., 2008). However, a

number of differences between the adult and aged psychiatric populations make it difficult to apply

this research to those aged 65 and over. This problem was identified by Speer (1990), who noted

that the differences between substances consumed, the level of polysubstance abuse and antisocial

behaviour between the two cohorts was notable.

Speer identified three further issues limiting the ability to compare these two populations.

The first concerned diagnostic criteria applied to aged psychiatry, with the author arguing that using

generalised criteria often resulted in lower rates of psychiatric disorders among older adults.

Secondly, Speer identified the high prevalence of chronic physical ailments among older adults.

Finally, Speer recognised cognitive impairment as an added complexity of many aged individuals.

Aged psychiatry itself tends to recognise this, with dementia being identified in the Diagnostic and

Statistical Manual of Mental Disorders, 5th Edition (2013). Therefore, those individuals with a

diagnosis of dementia and substance use disorder may also be considered dual diagnosis, as

discussed in the background chapter of this thesis. As Speer goes on to discuss, this difference in

itself has far reaching effects on assessment and treatment of substance use in older adults.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 73

These findings are reflected in Seitz et al’s (2012) study of adults admitted to psychiatric

beds in Ontario, Canada from April 1, 2008 to March 31, 2010. This information comprised 79,352

contacts, 6952 (8.8%) of which were 66 years or older. The authors then divided these individuals

into two cohorts, being 18-65 and 66 and over. By comparing these two groups using summary

statistics, the authors found that older adults were more likely to be living alone with significant

medical comorbidities. Similarly to Speer (1990), Seitz et al noted that 66.7% of the older adult

population were cognitively impaired when tested on a standardised instrument, and 19.5% had a

primary diagnosis of dementia. The authors concede “Older adults in APUs (acute psychiatric units)

are a socially, medically and functionally complex group, with significant care needs that may be

distinct from those of younger adults,” (p. 562).

The authors define this statement by describing their findings of the older adult cohort,

including “social vulnerabilities” such as social isolation. Almost one half of the sample were noted

to be separated, widowed or divorced. Further, the authors note a frequent occurrence of

polypharmacy and cognitive and functional impairment as distinct from younger individuals, with

older adults in the sample often requiring intensive follow up by allied health services, such as

physiotherapy and occupational therapy. Additonally, individuals in the sample often had a high

number of medical comorbidities to be managed simultaneously with their psychiatric illness,

further adding complexity to the management of older adults.

Moos, Mertens and Brennan’s (1995) study of 33,323 individuals discharged from 88

United States Veteran’s Affairs substance abuse treatment programs in 1991 found a number of

differences between older adults and middle aged and younger adult patients. The total sample was

divided into three cohorts, being those aged 18-34 (n=6,798), 35-54 (20,904) and 55 years of age

and over (n=5,621). Data was drawn from inpatient files and subsequent outpatient care episodes

from Veteran’s Affairs. Despite the large sample size of this study, the authors note a limitation in
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 74

that 97% of the sample was male, and therefore may not be representative of community treatment

services.

Despite this limitation, the research reveals a number of comparisons between the young,

middle aged and older adult cohorts that provide an ability to compare these populations and also,

demonstrate the need for further research specific to the older adult population. The authors found

that “Older patients had more complex and chronic substance abuse problems than did their

younger counterparts,” (p. 335). Older adults were also more likely to have an alcohol or drug

psychosis diagnosis, less likely to obtain mental health aftercare post inpatient admissions, less

likely to solely have an alcohol or drug dependence diagnosis (instead often having a comorbid

psychiatric or medical condition), and had higher readmission rates. Older people also had a heavier

prior use of inpatient substance abuse, mental health and medical services compared to younger

adults, and showed somewhat poorer outcomes after treatment. According to the authors, “…

confirming the idea that standard treatment approaches do not work well for older patients, more

than 60% of these patients had had recent prior inpatient care for their substance abuse disorders,”

(p. 340).

To further underscore the differences between the two populations, it was noted that

dementia was a primary diagnosis in 19.5% of the older adults, compared to 0.5% of those aged 18

to 66. The authors go on to conclude that the older adults “were a medically complex population,

with a high degree of both cognitive and functional impairment in addition to having significant

psychiatric needs,” (p. 561). Social isolation, often noted in those living alone, compounded the

care needs of the older adult population, which the authors conclude may increase risk for suicide,

and medical or psychiatric rehospitalisation, therefore requiring higher levels of social support and

community care.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 75

Chaput, Beaulieu, Paradis and Labonte’s (2011) study of data obtained from all adults

visiting a Canadian psychiatric emergency service in Montreal also sought to compare the 1349

patients 65 years or older to those aged 18 to 64 (n=14,230). The study found that those over 65

were often frequent repeat visitors. It was also found 7.5% of the older adult cohort had substance

use disorders as a primary diagnosis, and 19% as a secondary diagnosis to a primary mental illness.

Despite the authors reporting a “relative absence of substance use,” they do conclude that their

diagnosis coding methodology may have underestimated the true prevalence of substance abuse (p.

7). This compares to the finding that 18.5% and 28% of patients under 65 had primary and

secondary substance use disorders respectively.

Of the older adults that did have substance use disorders, it was found that 93% used

alcohol, 1% cannabis, 4% multiple substances and 1% benzodiazepines. This is a distinct contrast to

the 18-64 population, of whom 42% used alcohol, 18% cannabis and 32% multiple substances. The

authors go on to describe a “… constellation of core findings typical of the [psychiatric emergency

service] patient,” being underrepresentation in epidemiological data, a higher proportion of

affective disorders (chiefly depression), higher admission rates, gender being predominantly female,

few self-referrals and more frequent (prescribed) benzodiazepine use (p. 7).

In summary, significant differences exist between the older adult population and those under

the age of 65. In lieu of Australian research investigating the contrast between local adult and aged

dual diagnosis populations, it becomes difficult to apply the results of the large number of studies

exploring dual diagnosis in those under 65 to older adults. As the research here indicates, a number

of dissimilarities make it very difficult to apply these findings with any degree of reliability to older

adults. In itself, this notion justifies the need to conduct research into older Australian adults

experiencing co-occurring mental illness and substance use disorders.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 76

Neuropsychological effects of substance abuse.

The neuropsychological effects of mental illness are clearly documented, with research

documenting complex neurobiological interactions as causing marked cognitive decline in both

schizophrenia and bipolar affective disorder (Braff, 1993; Quraishi & Frangou, 2002; Ross,

Margolis, Reading, Pletnikov, & Coyle, 2006). Similarly, although more contentious, the effects of

alcohol on the ageing brain have also been reported, with the widespread acceptance of a number of

neuropsychological syndromes related to the excessive consumption of alcohol, however the

mechanism of these syndromes is debated widely (Carlen et al., 1994; Ridley, Draper, & Withall,

2013). What is not clear is the neuropsychological effects of comorbid mental illness and substance

use disorders in older adults, or with substances rather than alcohol. A shortage of research

examining older adults and both the pathological and behavioural changes as a result of alcohol or

other drug use is evident.

Mohamed, Bondi, Kasckow, Golshan and Jeste (2006) sought to describe neurocognitive

functioning in a sample of individuals 44 years and older, diagnosed with either schizophrenia or

schizoaffective disorder, who were outpatients at a Veteran’s Affairs Healthcare Service in San

Diego. These individuals were divided in to two groups according to the presence of a DSM-IV

diagnosis of alcohol dependence or abuse (n=52) or no diagnosis indicative of alcoholism (n=220).

A structured clinical cognitive assessment was performed with each individual, including a number

or tests of memory and verbal learning. It was found that older individuals with dual diagnosis had

lower scores relating to their cognition compared to those of the same age without a diagnosis of

alcohol dependence or abuse.

Similar results were found in Manning et al’s (2007) research into the cognitive function of

120 individuals from two community health services and one alcohol treatment service in London.

The sample comprised three groups, being 40 individuals with schizophrenia alone, 40 with alcohol
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 77

dependence alone and 40 with a dual diagnosis of schizophrenia and alcohol dependence. Cognitive

functioning was assessed using the Mini Mental State Examination (MMSE), with two instruments

used to determine severity of mental illness and two used to determine frequency and currency of

alcohol use. This testing methodology is not as comprehensive as the neuropsychological test

battery described in other studies mentioned here, with the MMSE originally being conceived as a

brief screening instrument for detecting the presence of cognitive deficits for further investigation

(Tombaugh & McIntyre, 1992).

Although this study encompassed a wider age range that that of Mohamed, Bondi, Kasckow,

Goldshan and Jeste, the results again demonstrated cognitive deficits in the dual diagnosis group,

recording lower MMSE scores, and recording the highest percentage (68%) of individuals meeting

the criteria for global cognitive impairment using recognised criteria. This group also had lower

scores in the domains of language, naming, memory and visual construction. Perhaps a more

interesting incidental finding of this study is that within the alcohol dependence group, 39 out of 40

participants screened positive on the mental health screening tool for problems such as depression,

anxiety or phobias, indicating a significant number of individuals with high prevalence psychiatric

disorders within this cohort.

Benaiges, Prat and Adan’s (2012) review of published studies concerning the

neuropsychological aspects of dual diagnosis found across younger ages contradictions in many

studies, with some reporting improved neuropsychological function relative to those with a

diagnosis of schizophrenia alone. Many authors hypothesised that this improvement in executive

function was likely due to two factors: a protective effect of younger age, and the need for fairly

advanced social and problem solving skills in order to maintain the networks necessary to procure

illicit substances.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 78

Despite this finding in younger subjects, Benaiges, Prat and Adan’s review of studies

concerning older adults found a marked neuropsychological deficit in individuals with a diagnosis

of schizophrenia compared to individuals without schizophrenia of the same age. Additionally, this

deficit was amplified in those who consumed alcohol, with worse abstraction, verbal perception,

word recall and long-term memory characterising what the authors describe as “ … a general

cognitive deficit … with a significant increase of the deficit in [subjects] 40s and 50s,” (p. 180). To

explain this finding, the authors postulate that a prolonged, chronic period of substance abuse

allows neurotoxic effects to become more evident in older individuals.

Herman’s (2004) comparison of 46 dually diagnosed individuals and 43 non-substance

abusing individuals with schizophrenia echoed the findings of Benaiges, Prat and Adan’s work.The

hypothesis of this research was that “… because of the neurotoxic, physical and medical effects of

substance and polysubstance abuse, the dually diagnosed will show greater neurocognitive

impairment and report a poorer quality of life compared to non-substance-abusing patients with

schizophrenia,” (p. 283). The results of the study failed to validate this hypothesis, instead showing

better performance on tasks involving domains such as executive function, planning and reasoning.

Additionally, those with dual diagnosis expressed a higher satisfaction with their quality of life

compared to those non-substance using individuals.

As this study relied on review of neuropsychological testing conducted on subjects whilst

inpatients in a metropolitan Sydney hospital, it is difficult to ensure inter-rater reliability. The

author also concedes that those without a comorbid substance abuse diagnosis scored significantly

worse on measures of psychiatric disability, as well as being younger (mean age 30.86 versus

42.17). The research does not provide insight into older adults, however demonstrates the variable

findings of the effect of substance use on mental health found in contemporary research.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 79

Herman offers a potential explanation for this unexpected finding, being that individuals

with dual diagnosis face a reduction of the stresses associated with substance use when admitted to

an inpatient unit, namely being a cessation in exposure to violence, criminality, concerns for

housing as well as food are abated, and the need to participate in activities such as sex work to

finance substance use. Although some of these elements may not be applicable to an aged

psychiatric population, Herman’s work is of interest to this study as it offers a potential argument

that the deleterious cognitive effects of substance use may appear over time, thus necessitating

differing approaches to those termed “lifetime” users as opposed to older adults who commence

substance abuse late in their lives.

To demonstrate these cumulative effects, Munro, Saxton and Butters (2000) employed a

cross sectional design to explore the potential ongoing neuropsychological effects of alcohol despite

abstinence in 36 individuals recruited from a Veteran’s Affairs substance abuse treatment program

and one private clinic in Pittsburgh, USA. All subjects met the DSM-IV criteria for alcohol

dependence, had been drinking for 10 years and over, and were aged between 55 and 83 years. The

individuals were split into two groups, being those abstinent for less than six months (n=18) and

those abstinent for over six months (n=18). These groups were compared to 17 control subjects,

with no diagnosis of alcohol abuse or dependence.

A neuropsychological test battery was performed with all participants of the research

project. The results determined that those with less than six months of abstinence performed

significantly worse than the control group, with the greater than six months abstinence group

performing equally with the control group in a number of tests. However, there was a trend of poor

performance in memory related tasks such as delayed recall and word list learning. The authors

concluded that “Scores for memory of a word list and for simple and complex figures indicated that
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 80

memory functions are vulnerable to the long-term effects of alcohol use among older people, even

with abstinence,” (p. 1514).

Potvin et al.’s (2008) cross sectional Canadian study of 53 patients of a Montreal health

service who met the DSM-IV criteria for schizophrenia, directly contradicted the results found by

Harman, finding poorer strategy and greater depressive episodes in individuals with a dual

diagnosis. The subjects were split into two groups, being dual diagnosis (n=30), and those with

schizophrenia with no substance use comorbidity (n=23). Mean ages for both groups were similar

to Harmin’s study, however closer between the two groups (32.9 versus 36.4). A comprehensive

neuropsychological assessment was performed, with performance on this task demonstrating

deficiencies with working memory. The authors go on to state that studies examining cognitive

performance in dual diagnosis patients have produced contradictory results, which is ascribed to a

number of factors. These factors include type of testing performed, level of substance or

polysubstance abuse and the types of medications used to treat the mental illness.

Despite some ambiguity in neurocognitive findings in younger patients, the research

indicates that substance use in the setting of dual diagnosis is deleterious to cognition in older

adults. The research literature focuses on alcohol use, thus leaving a substantial knowledge gap in

the effects of other substances in older dually diagnosed individuals. Additionally, the literature

identifies that a number of confounding variables, such as differences in testing regimes and

psychotropic medications, make accurate assessment of cognition difficult in dually diagnosed

individuals (Benaiges et al., 2012). Notwithstanding this, deleterious cognitive effects in older,

dually diagnosed adults add marked complexity to the management and treatment of these

individuals, therefore indicating a need for further research in this population.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 81

Suicide and risky behaviours.

Suicide is a well-documented phenomenon among both psychiatric and substance using

populations (Bailey et al., 2011). Risky behaviours, including criminal behaviours, risks to health

and harm related to substance use and mental illness are also well described in adult dual diagnosis

populations (Ogloff et al., 2004; David, 2012: Phillips, 2000). Unfortunately, literature describing

these issues in an older adult population is scant, mostly referring to the role of alcohol dependence

on suicide, or the long-term health consequences of intravenous opioid use, such as hepatitis and

HIV (Richard, Bell, & Montoya, 2000). Despite organisational policy documents indicating

potential harms as a consequence of risky behaviours in older dually diagnosed individuals,

research remains scant (Drugscope and the Recovery Partnership, 2014).

Wadd, Lapworth, Sullivan, Forrester and Galvani’s (2011) exploration of older drinkers

used a qualitative methodology, using a combination of one-to-one interviews and focus groups

with 15 alcohol and other drug practitioners, and 26 older adults aged 50 and over to attempt to

develop strategies to treat older adults presenting to five treatment services in the United Kingdom.

Despite criminal behaviour being identified by clinicians in older adults, a number of the client

participants in the research described instances where they had assaulted spouse or family members,

or damaged or stolen property.

A number of other risky behaviours were identified in the discourse, with a practitioner

describing an older couple who were targeted by local drug users offering to buy them alcohol and

taking financial advantage of them in the process, and an older adult identified by another

practitioner identifying a range of abuses in clients using alcohol, specifically identifying a client

with a friend assisting with managing the client’s finances, also taking financial advantage of the

client in the process.

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Abuse is further documented in Friedman, Avila, Tanouye and Joseph’s (2011) case-control

study. Data was generated from two trauma units in Chicago, identifying 41 cases of elder abuse.

These cases were compared to 123 controls. Retrospective audit of the trauma registry data was

performed, with cases being identified through a set of diagnostic codes entered into the registry for

each clinical occasion. Friedman et al (2011) found that 29.3% of these individuals tested positive

for alcohol on admission, with further narrative review noting that both the victim and perpetrator

had consumed alcohol prior to the assault. The authors note that “Victims of severe traumatic elder

abuse were more likely to be female, have a neurological or mental disorder, and abuse drugs or

alcohol,” (p. 420) which resonates strongly with this study given the authors are describing, in part,

a victim who fits the criteria for dual diagnosis.

Sorock, Chen, Gonzalgo and Baker’s (2006) population-based case-control study of 1,735

deaths from falls, motor vehicle accidents or suicides from the 1993 US National Mortality Study

versus 13,381 controls from the 1992 US National Longitudinal Alcohol Epidemiological Survey

found a number of associations between drinking and serious or fatal injury in older adults. The

authors noted drinking to be associated with a higher risk of motor vehicle accidents and falls, with

consumption of 12 or more drinks a year indicating a 50-70% increase in risk for both, as well as

suicide. Deaths from falls were noted to be associated with moderate to heavy drinking in men. The

study did note, however, that the percentage of heavy drinking tended to decrease as age advanced.

Kurtzhaler et al’s (2005) study of 615 individuals admitted to an Austrian emergency

department sought to investigate the role alcohol and benzodiazepines play in falls. The study

analysed blood samples which were obtained over a one-year period, with the mean age of

individuals experiencing a fall being 64.8 (SD ± 20.8). In concordance with Sorock, Chen,

Gonzalgo and Baker’s study, it was found that alcohol consumption was higher in males, and,

supporting the finding that heavy alcohol consumption declined with age, the lowest consumption
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 83

was found in individuals 70 years and over. In individuals up to 70 years old, it was noted that

alcohol consumption was higher in individuals injured due to a fall than in injuries due to other

causes, indicating that falling is a serious concern in adults who consume alcohol.

In regard to benzodiazepine consumption, 8.5% of male and 3.2% of female blood samples

contained benzodiazepine. It was noted that 3% of males and 0.3% of females had consumed both

alcohol and benzodiazepines prior to falling. Plasma concentrations of all individuals testing

positive to benzodiazepines were noted to be all within the therapeutic range or lower, perhaps

indicating that the individuals included in the study were taking benzodiazepines as prescribed by a

treating medical practitioner.

Carter and Reymann (2014) explored the use of emergency departments by older adults

attempting suicide in their research. Data from 22,444 visits by individuals 65 years and over was

extracted from the 2006 Nationwide Emergency Department Sample, which covers 20% of all

hospital-based emergency departments in the United States. Descriptive and multivariate statistical

analysis of the sample was performed, finding that approximately 46% of all visits made by adults

75 and over were made for suicide related injuries, with 49.2% of all older adult suicide related

visits involving some form of substance use. The authors describe trends in the literature regarding

rising suicide rates and drug use amongst the middle-aged adult cohort, speculating that this trend

will likely result in higher figures recorded as this population ages. Clearly, this is concerning

regarding the population under examination in this study and may indicate future demand for older

adult mental health services growing exponentially.

From an Australian perspective, De Leo, Draper, Snowdon and Kõlves (2013) case-control

study sought to identify the psychiatric and psychological factors contributing to suicide in older

adults in two Australian states, Queensland and New South Wales. Cases were identified from both
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 84

middle aged (35-59, n=188) and older adults (60 and over, n=73) using Coronial data, with clinical

interviews then being conducted with the next of kin of the deceased. These cases were compared

with “sudden death” controls (middle aged n=103, older adults n=79). Despite a poor response rate

in the next of kin group (46.6% for suicide cases and 36.5% of controls), semi-structured interviews

were conducted to determine the presence or absence of a number of predictive factors for suicide.

The results of the study found 61.6% of older adults had at least one psychiatric disorder at

the time of death, with mood disorders being the most prevalent. It was also found that psychotic

disorders and substance use were higher in the middle-aged cohort, however it should be noted that

13.7% of older adults had an alcohol use disorder, amounting to 10 individuals of the group of 73.

Despite this, the authors caution in their discussion that alcohol abuse remains an extremely

variable risk factor, being important in a number of countries yet less so in others according to other

published research. The most significant independent predictor, as noted in other studies in this

literature review, is living alone.

Although research regarding suicide and risky behaviours in dually diagnosed older adults is

scant, important learnings are found within the literature. Elder abuse, particularly in the financial

realm, is a topic that has generated much research. However, this research rarely includes specific

mental illness or substance using older adults. Likewise, criminal behaviour in older, dually

diagnosed adults is seldom a function of research interest, perhaps due to the notion of criminal

desistance theory, in which older adults are assumed to have ceased their criminal behaviours

earlier in life, much like the maturing out hypothesis discussed earlier in this literature review

(Paternoster & Bushway, 2009; Warr, 1998).

However, perhaps the most concerning reason for a lack of research exploring these issues

in older dually diagnosed individuals is a simple lack of identification and under diagnosis. With
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 85

studies citing alcohol and other substance use being frequently missed in assessment of older adults,

it may simply be a case of false assumptions that substance use disorders do not exist in older

individuals at a prevalence level justifying research effort (Clay, 2010; Loukissa, 2007).

Contemporary Treatment

This section explores contemporary assessment and screening tools applicable to the older

adult cohort. The section also examines the attitude of clinicians towards dually diagnosed

individuals, which many commentators in the dual diagnosis field have identified as a barrier to

effective treatment (Kenneth Minkoff & Cline, 2006).

Screening tools specific to the aged cohort.

Screening for alcohol and other drug use, although pivotal to a comprehensive psychiatric

assessment, is often neglected when assessing older adults. Badrakalimuthu, Rumball and Wagle

hypothesise that this may be due to a reluctance to enquire as to drug and alcohol use in older

adults, a lack of training or that addiction processes may be incorrectly attributed to delirium or

dementia (2010). When combined with a trend towards under diagnosis in older adults, the need for

formalised screening in all older adults becomes necessary in order to detect the presence of alcohol

or other substance use disorders (Crome et al., 2011). During the course of this literature review,

few studies were found assessing contemporary screening tools in older adult populations.

As identified in a Turning Point Alcohol and Drug Centre investigation into treatment needs

of older adults, screening tools need to be specific to older adult populations (Hunter et al., 2010).

Standard screens often incorporate social, legal and employment related domains of questioning

that may not apply to the older person, thus affecting the results of screening. The report also

contained a qualitative data phase, where a number of alcohol and other drug, community health

and general practice key informants expressed concern that contemporary screening tools were “…
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 86

not sufficient for understanding the full complexity and potential harms for older people,” (p. 40).

The key informants (n=17) felt that these tools needed to be expanded to explore additional

domains, such as life events that cause stress and grief, medical conditions, cognitive function, legal

problems, mood, and social concerns.

Several screening tools for alcohol and other drugs have been developed with the aim to

provide a formalised testing mechanism that is efficient, simple to administer and reliable when

used by a number of clinicians. The AUDIT, developed by the World Health Organisation, is one

such tool (see appendix H for the AUDIT). Babor, Higgins-Biddle, Saunders and Monteiro (2001),

in their manual describing the AUDIT, consider its utility in a number of situations, with the

development and evaluation of the tool taking place over two decades. Success with the AUDIT led

to the development of the DUDIT, a screening tool assessing specifically for illicit substances.

Despite the AUDIT being standardised cross-nationally, through a 1982 validation project

spanning six counties, formal validation with older adults has not been performed to date.

Notwithstanding this, the AUDIT remains the screening tool of choice for many health providers in

both the mental health and alcohol and other drugs fields. Philpot et al (2003) sought to evaluate the

AUDIT in older people by correlating the AUDIT with a clinical interview of 128 patients of a

community old age psychiatry service over a 7-month period during 1998-1999. The AUDIT was

compared with an older alcohol screening tool, the CAGE, which at the time was noted as the

predominant screening tool in use (see appendix H for the CAGE). It was noted that the AUDIT

was superior in detecting problematic alcohol consumption compared to the CAGE when statistical

analysis for sensitivity, specificity and positive predictive value was applied.

Another variant of alcohol screening test, the MAST-G (see appendix H for the MAST-G),

has been developed and validated on elderly populations. Hirata, Almeida, Funari and Klein (2001)
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 87

explored a random sample of 304 male patients of a geriatric outpatient service, aged 60 or over, in

a public teaching hospital in Brazil. Two geriatricians administered the standard MAST, with the 64

patients scoring 4 or greater assessed by a psychiatrist to determine the presence of alcohol abuse or

dependence in accordance with DSM-III-R criteria. As a comparison, 59 patients were selected with

a score lower than 4 for assessment by the psychiatrist. Compared to the “gold standard” of DSM

diagnostic criteria, the MAST fared well, with sensitivity and specificity values when applied to the

MAST score of 4 or more being 91.4% and 83.9% respectively. As the authors note, Morton, Jones

and Manganaro (1996) achieved similar results with the MAST-G in a study of 120 male veterans

aged 65 and older, although the intent of the development of the MAST-G, being greater sensitivity

and specificity on older populations, does not appear to have been realised in this study.

Johnson-Greene, McCaul and Roger (2009) also sought to validate the MAST-G in a

population of 100 individuals admitted to a US inpatient unit after acute stroke. Included

participants were noted to have “mild” cognitive impairment, however those with a severe sensory

impairment were excluded from the sample. A trained researcher administered the MAST-G, with

linear regression being applied in order to produce a short version (SMAST-G) with comparable

reliability and validity. The authors found a similar sensitivity at the 4-item level, being 89%,

however displayed a lower specificity at 42%. The authors describe this phenomena as being

possibly due to wording of many of the MAST-G questions, some of which imply recent events and

others that attempt to discern lifetime behaviours. The authors also caution that the MAST-G may

not perform well when attempting to detect current hazardous alcohol use, which is a fundamental

prerequisite for any screening tool used in a mental health setting.

Schonfield et al’s (2010) development of a pilot program of screening and brief intervention

in Florida, USA demonstrates the need for integration of effective screening tools as a key element

of successful, cost-effective treatment. Between May, 2004 and May, 2007, the project completed
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 88

3,497 full screenings of individuals referred to four agencies. A brief pre-screening interview was

utilised to determine potential substance use disorders, with those recording positive results invited

to participate in the full project interview. This interview screened for alcohol, illicit substances and

prescription medication misuse, as well as depression and suicide risk. The authors noted that the

screening protocol was useful for determining “hidden” cases often overlooked by more traditional

service methodologies, further highlighting the importance of effective screening tools in detecting

both alcohol and substance use disorders.

Returning to Hunter et al’s (2010) Turning Point Alcohol and Drug Centre study, the key

informants interviewed discussed screening and treatment implementation in a number of

situations. They noted that urgent care centres in the USA screen between 200 and 300 older adults

monthly, using brief interventions for positive screens (brief interventions are discussed in the

“contemporary treatment approaches” section of this literature review). Additionally, screening and

assessment takes place on an outreach model, in the individual’s home, incorporating a complete,

conversational style of health assessment where alcohol and other drug assessment is combined

with other questions regarding health status. Clearly, both the AUDIT, DUDIT and MAST-G tools

do not achieve this aim, rather providing a structured framework for clinicians to perform rapid

assessment of an individual’s substance use and its impact on their functioning. It is also of note

that the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is used in many

clinical settings with good reported validity, however the verification of this tool specifically in

older adults has not occurred to date (Humeniuk et al, 2008; Tiet, Leyva, Moos and Smith, 2016).

Contemporary treatment approaches.

Contemporary treatment for substance use disorders involves two broad categories of

therapeutic approach: psychosocial and pharmacological. Pharmacological treatments, including

methadone maintenance therapy for opiate dependence and novel medications such as acamprosate
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 89

and naltrexone to abate cravings related to alcohol have received varying reports regarding degrees

of success (Anton, O’Malley, Ciraulo, & et al., 2006; Fischer, Rehm, Kim, & Kirst, 2005).

Applying the complexities of comorbid mental illness to substance use requires the use of various

pharmacotherapy, including antipsychotic medications, and brings new challenges in respect of

adherence to regimens designed to promote either reduction of, or abstinence from, substance use

(Sreenath, Reddy, Tacchi, & Scott, 2010).

Moy, Crome, Crome and Fisher (2011) found in a systematic review of 16 studies

concerning treatment of substance use disorders in adults aged 50 or over that poor information on

the type of pharmacotherapy, dose, and criteria for prescription provided little support for

medications that could be considered safe and effective in older adult populations. Additionally, the

authors noted that follow-up periods for the majority of studies reviewed were less than a year,

making it difficult to draw conclusions about long-term outcomes, particularly when considering

the possibility of relapse over time. As these studies concerned mainly substance use treatment, it is

evident that the dearth of literature concerning older adults with dual diagnosis extends to treatment

modalities. As such, the following studies do not relate to older adults, however demonstrate the

approaches to treatment predominating the contemporary literature.

Outlaw et al. (2012) sought to determine the effectiveness of a treatment program in a

specialised community health centre in the USA, by completing a baseline and 6-month follow up

interview of 199 individuals who completed the program between January 2005 and October 2007.

The manualised program, based on cognitive behavioural techniques and relapse prevention

strategies, had participants meet weekly for 18 sessions. Additionally, case management services,

individual therapy sessions and medication supervision were provided. Program completers were

defined as those attending 14 or more sessions.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 90

Comparing completers of the program (n=84) and noncompleters (n=115), completers

showed cognitive improvement, including a reduction in the number of days they had trouble

understanding, remembering and concentrating, and a reduction in the use of non-medical

prescription drugs. Additionally, decreases in binge drinking and general alcohol use were recorded

from intake to the follow-up interview. Subjectively, participants also reported a reduction in stress

and improved emotional wellbeing, including feeling less depression and anxiety. Although this

study was not specific to an aged dual diagnosis population, it does indicate the potential for

integrated, intensive treatment for substance use disorders.

Boden and Moos (2009) examined dual diagnosis patient responses to standard substance

use treatment, finding that although reduction of substance use did occur, worse psychiatric

outcomes were experienced. The sample comprised 3,048 alcohol dependent male Veteran’s Affairs

patients, with one year and five year follow up completed with 80.4% of the initial sample. During

follow-up, it was found that patients with dual diagnosis were less satisfied, and felt less supported

with substance use treatment than those without a co-occurring mental illness. As the authors

comment, these findings tend to indicate the need for integrated treatment that focuses both on the

psychiatric disability as well as substance use disorders, rather than attempting to treat each

comorbidity in isolation.

The concept of integrated, specific treatment is addressed in a study performed by James et

al. (2004). The authors conducted a randomised control trial to determine the efficacy of a dual

diagnosis specific group therapy comprising weekly 90-minute sessions over six weeks.

Participants (n=58) were recruited from three community health centres in Western Australia and

randomised to an intervention group (n=32) that received the manualised weekly sessions tailored

to their stage of change, as well as mental health interventions, with the control group (n=31)

receiving a single educational session.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 91

Follow up was performed at three months, comprising three measures of substance

dependence and polydrug use, being psychopathology, quantity and level of AOD use. Paired t tests

showed a significantly greater improvement within the intervention group, with improvement in

psychopathology, drug abuse and need for antipsychotic medications. Reductions in cannabis,

alcohol and polysubstance use were also indicated when compared to the control group. Noted by

the authors were the limitations of the small sample size and inability to perform blinding

procedures regarding intervention status. The authors did note that retention in the study was better

than previous attempts at randomised control trials in this population, perhaps indicating a higher

motivation to change in the study participants, which is not necessary a common factor in dual

diagnosis populations (Martino et al., 2002).

Mangrum, Spence and Lopez (2006) attained similar results with integrated psychiatric and

substance use treatment in their research comprising 216 clients of three Texas dual diagnosis pilot

programs. The participants were randomised to either an integrated treatment program (n=123), or a

parallel treatment program (n=93), whereby mental illness and substance use disorder were treated

separately. Mean age of the participants was 36.5 years. The integrated treatment model operated

under a number of principles including assistance with medication management, housing, skills

training, community linkage and treatment tailored to the client’s stage of change.

Analysis involved baseline measurement of psychiatric hospitalisation and arrest rates, with

follow up being performed at one year. Logistic regression was employed to compare the two

outcome variables. This data analysis determined that the incidence of hospitalisation in the

integrated treatment group decreased, while the parallel treatment group had an increased incidence

of hospitalisation for psychiatric purposes. Similarly, arrest rates fell in both groups, however the

integrated group recorded a greater reduction whilst the parallel group arrest reduction was
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 92

marginal. As the authors note, several studies examining integrated treatment found similar

reductions in incidence of psychiatric hospitalisation and a decrease in days in hospital.

While there may be grounds for a fiscal argument that integrated treatment initially results

in long, expensive hospital stays, Timko, Chen, Sempel and Barnett (2006) found that significant

cost savings could be made by “… shifting the locus of acute treatment from hospital to community

care,” (p. 163). The research examined 7 Veteran’s Affairs substance use and psychiatric treatment

services in the USA. The services admitted a minimum of three dual diagnosis patients per month,

and were all attached to a community residential facility. A total of 230 participants were recruited

to the study, and as noted earlier, a common caveat to Veteran’s Affairs studies is that samples

often comprise a high number of males. In this case, 96.5% of the sample were men.

Mean age of the sample was 45.4 years old, with 173 assigned to hospital care and 57

undergoing treatment in a community residential facility. Bed access was identified as the primary

reason for the uneven distribution of the sample to hospital or community care. This limitation

aside, the study found that dually diagnosed individuals had better substance use outcomes when

assigned to community care, with assessment being made using an adapted Assessment of Severity

Index applied on admission and at one year. It was also found that individuals assigned to hospital

care had a higher number of mental health admissions, with longer stays from baseline to follow up.

The authors hypothesise that community care allows integration towards “normal” roles, such as

independence and illness management, along with avoiding the isolation and stigma associated with

hospital care.

In summary, the literature indicates that treatment for dual diagnosis is most successful

when occurring concurrently with any psychiatric treatment that may be taking place. To achieve

this treatment modality, it is apparent that health services must reconsider the way they deliver and
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 93

provide mental health services. Furnishing an argument that treating dual diagnosis effectively is

“too expensive” due to longer index admissions and the need for greater training among healthcare

providers may result in individuals effectively being committed to a high number of psychiatric

admissions throughout their lives. In respect of older adults, failing to manage dual diagnosis

effectively may lead to deleterious neuropsychological effects, risky behaviour and carer burnout.

The impetus to find cost effective, deliverable treatment interventions is imperative to tackle the

problems associated with co-occurring mental illness and substance use disorders.

Clinician attitudes to dual diagnosis.

As discussed in the Background chapter of this thesis, one of Croton’s (2005) commonly

identified barriers to system improvement for individuals with dual diagnosis involves the

judgemental attitudes of some clinicians, and a general attitude that substance use disorders are not

the “business” of mental health services. Accordingly, a number of researchers have sought to

investigate the attitudes of mental health clinicians working with individuals with co-occurring

substance use disorders, both to identify any impact on service delivery and explore the experiences

of consumers seeking treatment by services (Szirom, King, & Desmond, 2004).

Todd, Sellman and Robertson (2002) aimed to identify the barriers to optimal care for dually

diagnosed individuals in New Zealand by conducting a series of 12 focus groups involving 261

clinicians, consumers and family members. Focus group size ranged from 4 to 63 participants,

bringing into question the ability of participants to share their answers freely in the larger groups

(Zuckerman-Parker & Shank, 2008). The authors rationalised the necessity of using large groups in

order to sample geographic service regions across New Zealand. The key theme arising from

analysis of the responses was that of attitude issues, with it being noted that “… judgemental

attitudes about substance use often coloured the care that … patients received, especially from
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 94

mental health services,” (p. 794). A number of examples were cited by service users describing

individuals being denied mental health treatment due to a concurrent alcohol or drug problem.

Further, participants identified an “insistence on abstinence and confrontation,” with

individuals often pressured to stop using substances (p. 795). Little regard was given to attempting

to encourage individuals to reduce their use, or implement harm reduction strategies. This notion

seemed to stem from responses indicating that consumers of mental health services often believed

that clinicians implied that substance use was a matter of choice. This attitude, when combined with

the knowledge deficit identified by clinicians, led to a prevailing attitude that alcohol and other

drugs were “not the business of mental health services,” (p. 794).

The notion of inadequate preparation to care adequately for dually diagnosed individuals

was further explored in Deans and Soar’s (2005) qualitative study of 13 mental health professionals

working in a Victorian regional community mental health service. In depth interviews were

conducted with a convenience sample being employed to recruit 10 nurses, one social worker, one

psychiatrist and one psychologist. Participants described feelings of anxiety, nervousness and being

overwhelmed when caring for complex dual diagnosis consumers, often related to the perception

that they were not adequately prepared during their university education. This knowledge deficit led

to a number of negative emotions being experienced toward dual diagnosis consumers, which the

authors describe as influencing both professional judgement and coping responses.

Van Boekel, Brouwers, Weeghel and Garretson (2014) conducted a questionnaire of 180

general practitioners (GPs), 89 healthcare professionals working in general psychiatry and 78

addiction specialists in the Netherlands in order to determine attitudes towards working with

individuals with substance use disorders. The findings, echoing that of Deans and Soar, indicate that

the addiction specialists had the highest regard for working with substance using individuals,
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followed by GPs and mental health professionals. The questionnaire instrument also sought to

examine attitudinal and emotional beliefs towards individuals with substance use disorders, finding

that the differences in regard were not related to emotional or attitudinal beliefs of health

professionals. Rather, higher regard was a result of greater exposure to working with individuals

with substance use disorders, knowledge of treatment systems, and a belief that successful addiction

treatment was possible.

Coombes and Wratten (2007) used a purposive sample of seven mental health nurses

working with dual diagnosis in a community setting in England. Data collection took place through

semi-structured interviews. Again, poor preparation for working with this consumer group was

identified, with participants all identifying that dual diagnosis was not covered in their initial

education. Despite this, participants often felt that they were soothing the anxieties of colleagues

encountering substance using clients, with descriptions of other healthcare workers having a great

deal of reluctance to work with substance using individuals. One participant described health care

professionals going to great lengths to avoid seeing dual diagnosis clients, with the general notion

that these clients were “someone else’s problem” due in part to a fear of being held responsible for

their actions. These prevailing attitudes often led to other services, such as GPs, excluding difficult

cases.

One participant stated “The old school of thinking is that there is nothing that can be done

for these people. They are seen as a waste of space - a waste of resources,” (p. 384). This was often

expressed in the research, with other healthcare professionals expressing this sentiment by treating

individuals with a dual diagnosis as a lower priority, and a waste of time. The participants described

this as a source of frustration, often having to deal with prejudices, assumptions and negative

attitudes expressed by colleagues. This was confounded by the perception that members of the

participant’s own mental health team often viewed dual diagnosis strictly in line with the medical
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 96

model, with consultant psychiatrists often demanding abstinence from clients while neglecting to

explore the social and economic issues inextricably linked with dual diagnosis.

To balance this perspective, Staiger et al (2011) used a purposive sample to recruit 44

individuals with a high prevalence mental illness and concurrent alcohol or other drug disorder to

participate in semi-structured interviews that sought to explore their experiences of mental health

services, with thematic analysis being conducted to discern prominent themes. Two overarching

themes, barriers to treatment and improving services, were identified. Participants described

structural barriers, including delays in response during times of crisis as a result of feeling

dismissed, unheard or judged when presenting at service entry points seeking help. These entry

points included emergency departments and mental health triage services.

The authors note a number of participants indicated a need for healthcare workers to

undertake further training and education in order to reduce judgemental attitudes experienced by

individuals seeking assistance from mental health services. Again, staff at entry points featured in

the narrative, often demonstrating a clear lack of compassion and empathy, and implying through

their communication with individuals that they felt them to be an imposition. Participants also went

on to describe positively a local integrated mental health and alcohol and other drug service, where

they felt healthcare workers provided a friendly, respectful, non-judgemental and practical service,

indicating the difference clinician attitudes make in the positive experience of service users.

Although the aforementioned studies did not explore attitudes of clinicians towards older

adults with dual diagnosis, they indicate the problem Croton identified as a barrier to improving

system responses accurately (2005). During this literature review, no studies specifically exploring

the attitudes of clinicians towards dually diagnosed older adults were located. However, it is of note

that a number of authors exploring the topic attribute attitudinal issues to a lack of training and
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 97

educational preparedness. This finding in itself provides justification for the third phase of the

current study, which seeks to explore both the attitudes towards dual diagnosis and perceptions of

educational preparation to manage this cohort within the MAPS team of clinicians.

Future Challenges

Aged psychiatry faces a number of potential challenges in respect to dual diagnosis in the

future. Some of these challenges are explored in this section. These challenges by no means

represent the entire spectrum of issues into the future, particularly with the emergence of new and

novel drugs (Khey et al., 2014). Despite this caveat, the following section presents three emerging

challenges to aged psychiatry services.

Methamphetamine.

At present, methamphetamine presents a significant future challenge to aged psychiatry

services. In the Australian context, methamphetamine began to gain traction in the drug market in

the last two decades, pushing aside heroin as the abused illicit substance of choice for many due to

its lower cost and constant availability. Methamphetamine is also becoming a genuine alternative

for drug smugglers, dealers and manufacturers due to the ability to make the drug with a number of

easily obtained precursor chemicals in clandestine laboratories, thus avoiding the need for elaborate

importation concealment (McKetin & McLaren, 2004).

In respect of older adult mental health services, methamphetamine presents a number of

unknown factors that will likely be faced in the coming decade as users age. According to the

Australian Crime Commission (2014), seizures of amphetamine-type stimulants (methamphetamine

and 3,4-methylenedioxymethamphetamine [MDMA]) for the year 2012-2013 are the highest on

record. This report indicates that worldwide, methamphetamine is the second most used illicit drug
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 98

after cannabis, and demonstrates a steadily increasing trend of detections of amphetamine-type

stimulants since the 2003-04 reporting period. Domestically, the majority of the 757 clandestine

drug laboratories detected during 2012-13 were manufacturing amphetamine-type substances, and a

large proportion of surveyed drug users (88%) reported crystal methamphetamine (“ice”) as easy or

very easy to obtain.

Irvine et al. (2011) performed a wastewater analysis in South Australia to determine a true

prevalence of methamphetamine use in Adelaide and regional South Australian towns. The

analysis, conducted from April 2009 to October 2009, involved taking sewage samples from inlet

pipes of a number of treatment plants. The samples were then analysed for metabolic markers of a

number of illicit substances. Results from the analysis demonstrated methamphetamine and MDMA

prevalence at rates 10-40 times higher than European countries. This finding demonstrates the

significant differences between Australia and both the United States and Europe regarding

substance morphology, showing a clear preference for methamphetamine use in Australia.

Lowfall, Schuster and Strain (2008) explored a United States treatment episode database for

the years 1992-2005 to determine whether the profile of older adults entering substance use

treatment had changed. Admissions per year were from 1.55 million in 1992 to 1.85 million in

2005, with 75,899 of these individuals being 55 years or older. During this period, data obtained

from the treatment database indicates a rise in methamphetamine as a primary substance used in

adults 55 years and over from virtually none in 1992 to 1.4% of the sample in 2005. Adults 50-54

years old rose from the same position to 2.6%. Although statistically small in respect of

percentages, this figure accounts for nearly 7,500 older adults using methamphetamine as a primary

substance. Unfortunately, comparison to an Australian sample is impossible due to a dearth of local

data concerning older adults.

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As these studies demonstrate a definite cohort of methamphetamine users, with increasing

numbers in the older adult cohort, it is timely to question the lasting effect of the use of

amphetamine-type substances on cognition over time. Given that aged psychiatric services often

manage cognitive decline, both as a result of organic processes and chemical insults (such as

alcohol and other drugs), ageing methamphetamine users may pose a substantial challenge to the

clinical capabilities of services. As Barr et al. (2006) note, “[Methamphetamine] is a

psychostimulant drug that acts on the central nervous system … causing the release of monoamine

neurotransmitters, including dopamine, [noradrenaline] and serotonin,” (p. 302).

Barr et al. reviewed contemporary research concerning the neuropsychological effects of

methamphetamine use, with animal studies indicating that neurotoxic effects tend to last for months

or years. These neurotoxic effects include the loss of dopamine terminals in the brain. In human

subjects, research discussed by the authors has found a reduction of dopamine levels in the brains of

long term methamphetamine users in the vicinity of 50-60%. These changes in cerebral tissue tend

to manifest as “… profound neuropsychological effects,” (p. 306), including attention, working

memory and executive function deficits. These structural neurotoxic defects are reported in a

number of other studies (Cadet, Krasnova, Jayanthi, & Lyles, 2007; Jeong et al., 2013), including a

twin study where the neuropsychological deficits of stimulant abuse persist for at least one year

from abstinence (Toomey et al., 2003). However, perhaps the most challenging aspect of

methamphetamine use in dual diagnosis is that of psychosis precipitated by use of the drug.

In a multi-site study of methamphetamine-induced psychosis spanning four countries, Ali et

al. (2006) found 98% of Australian users of the drug had experienced persecutory delusions, 68%

auditory hallucinations and 88% delusional ideas. The study, conducted simultaneously across

Australia, the Philippines, Thailand and Japan, involved structured interviews and questionnaires to

a total of 193 participants. The participants were adults 18-59 years old who had been admitted to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 100

hospital for methamphetamine-induced psychosis. Non-drug induced psychotic disorders, such as

schizophrenia, were excluded from the study.

In addition to the psychotic symptoms mentioned, 30% of the Australian sample

experienced disorganised behaviour. Differences in the morphology of the psychosis was noted

between the four countries, however Australian methamphetamine users tended to suffer a higher

number of positive symptoms (such as hallucinations and delusional thinking), of a more severe

nature than the other countries included in the study. As noted in the level of drug use across the

four samples, Australian participants recorded higher levels of dependence or abuse; they also self-

reported higher cravings for methamphetamine.

Another significant concern in methamphetamine use is the harm associated with injecting

the drug. The majority of methamphetamine users in Australia inject the drug, which is a shift from

earlier use that noted smoking or snorting as the preferred routes of administration (Australian

Crime Commission, 2014). Accordingly, users open themselves to a number of harms associated

with injecting drug use. Fairbairn et al. (2007) found in a study of 1587 Canadian injecting drug

users a similar shift to injection of methamphetamine, with a high degree of syringe sharing noted

with use of the drug. Participants were followed between May 1996 and December 2004, providing

blood samples and participating in clinical interviews at baseline and twice yearly. The sharing of

injecting equipment brings substantial risk of blood borne viruses, including hepatitis and human

immunodeficiency virus (HIV).

Similar results were found by Nyamathi et al. (2008) in a study of 664 homeless individuals

in Los Angeles. Recruitment was via a number of homeless shelters participating in the research

and involved a number of questionnaire instruments administered to participants between

September 2003 and June 2006. The mean age of participants was 42. Approximately one quarter of
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participants reported lifetime methamphetamine use, with 27% reporting injecting. Again, the risk

of blood borne viruses via syringe sharing was noted as a significant risk of this behaviour.

Iudicello et al. (2014) examined the combined neuropsychological effects of

methamphetamine and HIV in a study of 210 individuals recruited as part of an HIV and ageing

program in San Diego. Among the participants were 116 adults aged over 50, who were compared

to adults 40 years or younger (n=94). The study found detrimental effects of prior

methamphetamine dependence on the cognitive performance of individuals with HIV. Of relevance

to a MAPS cohort is the notion of the authors, supported by prior studies in this area, that deficits

accelerate after age 50. Also noted was an association between earlier age methamphetamine

dependence diagnosis and poorer overall cognitive performance.

Although of concern to researchers in the present age, methamphetamine looks to present a

number of serious challenges to aged psychiatry services in the future. As the research examined in

this section indicates, neurocognitive performance may be seriously compromised in long-term

methamphetamine use, potentially leading to a cohort of individuals displaying dementia-like

symptoms akin to those displayed through long-term alcohol abuse. The burden of psychotic illness

associated with the use of this drug, combined with the potential complications from HIV infection

associated with syringe sharing behaviours, may prove to be a huge challenge to services despite

competency with individuals with dual diagnosis. As is observed in contemporary adult mental

health settings, methamphetamine may well become the greatest challenge faced by aged psychiatry

in years to come (Gonsalves, Sapp, & Huss, 2007).

An ageing methadone population.

Long hailed as the answer to opiate addiction, methadone is an orally administered opioid

with a long half-life. Described by supporters as reducing illicit drug use, criminal behaviour and
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bloodborne infections while increasing social participation, methadone programs in Australia have

undergone significant increase in capacity since their introduction (Bammer, Battisson, Ward, &

Wilson, 2000). As of October 2012, 14,085 individuals in Victoria were enrolled in methadone

programs (Department of Health, 2013c). However, methadone poses a number of challenges to an

ageing population of drug users. These challenges, as indicated in the literature below, primarily

relate to a high degree of co-morbid mental illness, ongoing substance use and neuropsychological

consequences of long-term exposure to opiates.

Rosen, Hunsaker, Albert, Cornelius and Reynolds (2011) conducted a systematic literature

review of studies related to heroin addiction in adults 50 years of age and over. A number of these

studies recruited their sample from methadone maintenance programs in the United States. These

studies indicated that older adults experience significant societal challenges and stigma related to

their drug addiction, ageing, HIV status, mental health and participation in the methadone program

itself that caused definite problems with both accession and retention in substance abuse treatment

programs. Additionally, despite these individuals being enrolled in a program designed to treat their

substance abuse, high rates of mental illness (primarily depression) were reported.

Rosen, Smith and Reynolds (2008) recruited participants from a methadone clinic in the

United States to examine the extent of co-occurring mental illness. Participants were 50 years of

age and over. One hundred and forty adults were interviewed and a comprehensive mental and

physical health testing battery was applied. Additionally, urine drug screens were conducted

regularly as part of the clinic’s procedures, with participants giving consent for these to be

monitored as part of the study. Of this sample, 57.1% were identified as having a co-occurring

mental health diagnosis, with major depressive disorder being most prevalent. Additionally, 47.1%

of the sample were taking psychotropic medication for a mental health problem.
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In addition to the complexity of what is effectively a dual diagnosis population being

managed by substance treatment services, general practitioners and pharmacies, methadone does

not guarantee abstinence from illicit substances. 61.9% of the sample had returned a positive urine

screen in at least one month during monitoring. Additionally, the prevalence of alcohol use was

high, with 21% of the sample reporting consuming four or more alcoholic beverages in one day in

the twelve months prior to interview. These findings are supported by those of Rowe (2003), who

found in qualitative interviews of individuals in St Kilda, Melbourne, that a large number of heroin

users believe that methadone is ineffective, with most of their acquaintances using illicit substances

in addition to their methadone dose.

Lofwall, Brooner, Bigelow, Kindbom and Strain (2005) reported similar findings in a

comparative study of 41 older (50-66 years of age) and 26 younger (25-34 years of age) opioid

maintenance patients in the United States. Sixty-five individuals in the sample were maintained on

methadone. Assessment by trained interviewers focussed on administration of a number of tools for

mental and physical health, in addition to addiction severity. Statistical comparison found that older

participants were likely to be in treatment for longer and be less likely to be receiving medical

assistance, partially echoing the findings of Rosen et al.’s aforementioned literature review.

Major depressive disorder was again found to be the most common co-occurring mental

illness in both the older age and younger group. The authors also noted that “… study participants

had high rates of many lifetime and current psychiatric diagnoses compared to general-population

samples,” (p. 270). Urine drug screens in this sample showed a smaller percentage of illicit

substance use, however cocaine, cannabis and benzodiazepines were found in the older adults. This

smaller percentage may be due to the shorter timeframe for examination of urine drug screens

compared with Rosen et al., being 16 weeks rather than 24 months.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 104

Rosen (2004) used a review of administrative data at a methadone clinic in the United States

involving clients over the age of 50 (N=143) to explore illegal drug use. Analysis of the dataset

focussed on demographic variables, life stressors, exposure to drug use and illegal drug use in the

past month. Illustrating a trend in the literature, 30.1% of the sample returned a positive urine drug

screen in the last month. Statistical analysis discerned that exposure to illicit substances in social

networks and neighbourhood settings was strongly associated with the use of illegal drugs in the

past month.

In addition to co-occurring mental illness and ongoing illicit substance use, Baldacchino,

Balfour, Passetti, Humphris and Matthews (2012) meta-analysis of published studies regarding the

neuropsychological consequences of chronic opioid use indicates that impulsivity, verbal fluency

and verbal working memory dysfunction are the consequences of ongoing use. As opiate

substitution with methadone means continued exposure to opiates rather than cessation, it must be

assumed that this neuropsychological dysfunction will continue. Twenty studies were included in

the meta-analysis, with samples comprising adults 18 years and over with opiate use or dependence

lasting at least six months. When potentially combined with the deleterious effects of other

substances, prolonged mental illness and poor health, the cumulative burden of these deficits may

amount to considerably difficult behaviours in older age.

The findings of Baldacchino et al.'s meta analysis are supported by Yücel et al.'s (2007)

study of 30 opiate dependent subjects recruited from community drug and alcohol services and

opiate prescribing general practitioners. These individuals were compared with 30 healthy

volunteers matched to intelligence, age and gender of the opiate dependent group. All subjects were

required to complete a functional task designed to examine neural behavioural regulation networks

whilst undergoing magnetic resonance imaging (MRI) scanning. The findings indicated

abnormalities of behavioural regulation, with a number of compensatory mechanisms begin

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 105

engaged within the brain to account for these abnormalities. The authors note that these

compensatory mechanisms, although allowing normative performance in testing, are prone to fail in

real-life situations due to a number of emotional and motivational influences, such as craving, stress

and withdrawal, indicating promise for further research explaining the role of these deficits in

opiate addiction.

Methadone, although often hailed as the solution to the complexities of opiate addiction

presents a number of significant challenges to aged psychiatric services. As indicated by research

conducted with individuals enrolled in methadone clinics in the United States, this population may

represent a large population of individuals with dual diagnosis being managed by drug and alcohol

services. As indicated by studies demonstrating structural and neuropsychological abnormalities of

chronic opioid use, these individuals may require enhanced support as they age and these cognitive

deficits become more difficult to manage in the primary health sector. With the added complexities

of ongoing illicit substance use, it is reasonable to conclude that these individuals will come to the

attention of aged psychiatric services in the future.

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The baby boomer generation.

Baby boomers, defined as individuals born between the years 1946 and 1964 are a

generation posing a number of challenges to public policy makers. This substantial group are the

result of an increase in birth rates worldwide after the second World War. As well as enjoying

greater fiscal freedom, the baby boomer generation has been shown to live longer and is currently

moving into “old age” (Biggs, Phillipson, Leach, & Money, 2007). Due to their sheer numbers,

baby boomers herald the notion of an ageing population, experienced not only locally but

worldwide. Australian Government projections recognise this demographic shift, predicting that the

proportion of the population aged over 65 years will double to around 25 percent of the entire

population over the next 40 years (Australian Government, 2004).

The implications of an ageing population for health services are clear. Greater demands for

healthcare will result in greater competition for finite resources. Treasury modelling has indicated

that population growth in the 15 to 64 age bracket over the next 40 years is expected to slow to

almost zero, resulting in reduced taxation to pay for the greater demand for services (Australian

Government, 2004). In respect of MAPS, a service that manages adults 65 and over, demand could

be expected to grow at an unprecedented rate without commensurate budget increases, requiring

novel solutions to deliver mental health care within a tight fiscal framework.

In respect of dual diagnosis, several authors have postulated that an increase in older adults

will result in greater substance use disorders, especially given most baby boomers have aged with a

differing perspective or experience on drug use compared to current aged adults. Duncan,

Nicholson, White, Bradley and Bonaguro (2010) describe America’s baby boomers as having “ …

greater racial and ethnic diversity, higher levels of education, lower levels of poverty, fewer

children, higher divorce rates, and more openness regarding their sexual orientation than any other

previous cohort of American older adults,” (p. 238). Additionally, their research sought to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 107

determine whether the notion of ageing substance users as being mainly alcoholics is correct in the

face of the significant differences of the baby boom generation.

The research examined 918,955 admissions of adults 55 and over to national substance

treatment services via a treatment episode database from 1992 to 2006. During this time period, it

was found that the proportion of admissions for alcohol abuse had declined from 81.7% in 1992 to

51.6%, and that admissions for other drug use had climbed from 10.3% to 32.5%. These statistics

demonstrate the changing morphology of substance use, with the research also finding support for

the hypothesis that the ageing baby boom generation would result in increased treatment admissions

for substance use disorders.

A similar study was conducted by Lay, King and Rangel (2008), who examined two cohorts

of adults aged 55 and over who were admitted to a United States inpatient addiction treatment

facility from 1992 and 2002. Retrospective chart audit was the methodology employed, resulting in

an overall sample of 116 individuals - 49 in 1992 and 67 in 2002. In the 1992 cohort, none of the

individuals reported use of cocaine, heroin or marijuana. By 2002, 10 individuals (16% of the total

cohort) were diagnosed with either dependence or use disorders of these substances.

More relevant to the study of dual diagnosis in this thesis, the total rate of prior psychiatric

treatment in both cohorts was 27%. However, more individuals in the 2002 cohort (34%) were

diagnosed with mental health problems during their treatment episode than the 1992 cohort (10%).

The authors do attempt to explain that this variance may be due to enhanced psychiatric screening

and treatment rather than a growth in mental illness diagnoses between the cohorts, however this

proportion of the sample does represent a significant number of individuals with a potential dual

diagnosis. Additionally, these results demonstrate the diversity of older adults presenting for
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substance abuse treatment as the baby boomer cohort ages, being “ … no longer a homogenous

population of alcohol-addicted individuals,” (p. 122).

The incidence of substance using baby boomers with co-occurring psychiatric disorders is

addressed in DiNitto and Choi’s (2010) study of cannabis use among older adults in the United

States. The study examined data from the 2008 National Survey of Drug Use and Health,

comprising 5,325 respondents 50 years and older. This data was obtained from a greater

questionnaire, administered using computer assisted personal interviews, with a component of the

survey exploring past, non recent and current use of cannabis, demographic data, psychological

distress and alcohol or other substance use or prior treatment. Bivariate statistical analysis was

conducted, finding that past-year users reported significantly more psychological distress, an

increase in older adults using cannabis and a substantial proportion of long-term users. The study

also found that past-year users were less likely to receive mental health treatment, raising the

question of whether cannabis use poses a barrier to seeking treatment or becomes a form of coping

with the symptoms of mental illness or psychological distress.

Colliver, Compton, Gfroerer and Condon’s (2006) work sought to project current drug users

50 years and older in 2020 by using data from the 1999, 2000 and 2001 United States National

Household Surveys on Drug Abuse. Logistic regression analysis was performed on the data to

describe the relationship between independent variables and current drug use in 2000, and a

predictive model developed in order to predict the prevalence of use in 2020. This analysis

indicated that drug users 50 years and older would increase due to a predicted population increase

of 52% in the over 50 age group by 2020, in line with Treasury modelling of the Australian

population described earlier.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 109

Additionally, the projected increase in marijuana users 50 and older was 355%, from

719,000 to 3.3 million. Use of any other illicit drug was projected to increase from 1.6 million users

to 3.5 million users, and non-medical psychotherapeutic drug use from 911,000 to 2.4 million.

These figures demonstrate a substantial increase, with the authors providing a caveat that the effects

of retirement had not been factored into this modelling and may alter predictions, either through

resumption of previous patterns of drug use from earlier years or decrease or cessation of use due to

the relief of the pressures of a working role.

The concept of retirement having an effect on substance use was explored by Bacharach,

Bamberger, Sonnenstuhl and Vashdi (2008) in their research exploring the conditioning role of

retirement on drug abuse. Telephone interviews were conducted with 978 blue collar, retirement

eligible employees, querying drug use through the application of a validated screening instrument

and collecting demographic data. The mean age bracket of the participants was 54-58 years. The

findings indicated that 26% of the sample “ … reported having at least one problem relating to drug

abuse, and over 2% reported a level of addiction high enough to justify formal, clinical

assessment,” (p. 1613). It was also noted that younger retirees reported more drug related problems

than older retirees, however younger retirees who continued work reported fewer drug related

issues than older retirees.

The demographic shift of baby boomers poses a number of challenges to contemporary

healthcare, and aged psychiatry services are in no way immune from these challenges. The research

critiqued in this section indicates a burgeoning over 65 population with an increasing number of

substance using individuals amongst them. This literature also demonstrates the potential for a

“hidden” dual diagnosis population whose need for mental health treatment may only become

apparent as they become older, more reliant on physical health treatment or cognitively impaired.

Accordingly, planning for baby boomers should be essential for aged psychiatry services,
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particularly when considering the potential impact of reduced health spending due to a smaller pool

of taxpayers.

Summary

This chapter has sought to examine the literature concerning dual diagnosis. During this

process, it was apparent that a number of other works influenced both the contemporary state of

play concerning dual diagnosis, heeding the potential consequences of co-occurring drug use and

mental illness. This chapter has also illustrated a number of challenges that may prove to test the

ability of older adult mental health services to deliver efficient, timely and cost-effective mental

healthcare to older adults as they age.

It is clear that a number of obstacles exist in providing the model of care envisioned by the

Victorian State Government in their policy document Dual diagnosis: Key directions and priorities

for service development (Victorian Government Department of Human Services, 2007). Despite

being recognised in this document as posing increased risks to health and wellbeing, and poorer

treatment outcomes, dual diagnosis still struggles to be the “core business” that the document

predicted. Surveillance of the literature tends to indicate that older adult mental health services may

be the least prepared of all mental health services in respect of responding to dual diagnosis.

This chapter has cohesively demonstrated an impetus for Australian based research

concerning dual diagnosis in older adults. Service based research, such as that conducted in this

thesis, enables both consumer and clinician involvement in formulating treatment improvements to

address the current service deficit existing in mental health services. The next chapter will describe

the process employed to conduct the research that forms the basis of the transformation of service

delivery to be more responsive to the needs of older adults with co-occurring mental illness and

substance use disorders.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 111

Chapter Four

The Research Process

Introduction

This chapter will provide an overview of the research methods used to achieve the aims of

this study. The study took place as a three phase, mixed methods process in order to answer the

research questions posed in the introductory chapter of this thesis. These research questions sought

to determine the prevalence of dual diagnosis in the MAPS consumer population, identify the

experiences of consumers with dual diagnosis and seek the input of MAPS clinicians caring for this

cohort. This chapter will provide an overview of the data collection process, steps of data analysis,

process utilised to achieve rigour and validity and finally, an overview of the relevant ethical issues

considered when undertaking this study.

An Overview of the Research Process

In order to address the research questions posed in the introductory chapter, a three-phase

explanatory sequential research process was undertaken. The initial phase of the process sought to

determine an approximate prevalence of dual diagnosis presentations to MAPS. Phase one used a

file audit to determine the prevalence of alcohol or other drug use (Moss, Gorrell, & Cornish,

2006). In the context of this limitation, the file audit also had a benefit as a quantitative data

collection tool: analysis of the quality of assessment for alcohol or other drug use in the

computerised record not only determined prevalence, but also assisted with determining the

responsiveness of the current mental health system to older adults with dual diagnosis.

The second phase of the study used semi-structured interviews with current clients of MAPS

(n=6) who were confirmed users of alcohol and other drugs. This qualitative process attempted to
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explore the experiences of drug and alcohol use, service interaction, individual complexity and the

interplay between the use of substances and mental health. Brief participant medical and psychiatric

history formulations are presented in this phase of the research in order to provide context to the

experiences and opinions of the participants themselves. The decision to present this information is

recognition that individuals who consented to participate in this phase of the research either had

long medical, psychiatric and substance use histories, or complex factors that led to a late onset of

drug or alcohol use.

The third phase of the project used a semi-structured interview to ascertain the experiences

of clinicians in caring for older adults with dual diagnosis. This phase also sought service

improvement recommendations from clinicians who are involved in direct care with this patient

cohort, as well as indicating potential attitudes and service barriers that may impinge on service

delivery to older adults with dual diagnosis (Croton, 2005). The interview questions for this phase

of the project were guided not only by the literature concerning the topic, but by the experiences of

consumer interactions with mental health services and suggestions for service improvement.

Setting of the Study

The setting of this study was the geographical Victorian Government inner south east aged

person’s mental health service catchment area. Alfred Health, the parent health organisation of both

Caulfield Hospital and MAPS, is contracted by the Victorian State Government to provide mental

health services for this area, comprising the local government areas of Port Phillip and Stonnington

and the Glen Eira-Caulfield statistical local area (a graphical representation of this catchment area is

presented in Figure 2). The 2011 census accounted population for this catchment area was 265,142

individuals, with 34,113 being age 65 or over (Australian Bureau of Statistics, 2011a, 2011b,

2011c).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 113

Figure 2. Graphical representation of the MAPS geographical catchment area. Permission granted by Melway Publishing
(2014).

The catchment area is highly diverse, comprising a wide variation of income levels. Areas

of considerable disadvantage co-exist alongside some of the most expensive real estate in

Melbourne. Areas within the catchment area contain a high proportion of single room and boarding

house accommodation in the State of Victoria, along with a number of public housing estates and

individual properties (Birrell, Healy, Rapson, & Smith, 2012). The disadvantaged population,

particularly around the suburb of St Kilda in the Port Phillip local government area, is highly

transient and a number of health, outreach and social services are situated in this suburb catering to

this population (City of Port Phillip, 2014).

The Port Phillip local government area comprises an area of 11km of foreshore fronting Port

Phillip Bay, with a number of entertainment and leisure precincts, office and industrial,

warehousing and manufacturing areas. Substantial increases in residential development have

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 114

occurred in this area, with a concomitant increase in property prices occurring and a gradual process

of gentrification changing the demographic substantially. The Stonnington local government area is

mainly encompassing residential and commercial areas, with a large proportion of retailing, with

tightly held pockets that are known as some of Melbourne’s most expensive housing stock. The

Glen Eira-Caulfield statistical local area is comprised of mainly residential areas with associated

retail. All three areas comprising the MAPS catchment are culturally diverse, with more than 28

different languages spoken and approximately 37% of the population born overseas (Australian

Bureau of Statistics, 2011a, 2011b, 2011c).

The population within the MAPS catchment area is noted to be ageing, with growth in the

65-70 age group predicted to grow an average of 31% to 2022. Currently, the largest age group

within the MAPS catchment is the 20-39 age group, which is conversely predicted to fall by 15% to

2022 (Australian Bureau of Statistics, 2011a, 2011b, 2011c). These predictions indicate the

changing demographic characteristics of the catchment area and the future challenges highlighted in

this thesis.

The Mixed Methods Design

As mentioned in the introduction of this chapter, a mixed methods design was selected for

this study as it was deemed the most appropriate approach to answer the research questions posed in

the introductory chapter. This section defines the concept of mixed methods research in addition to

providing a rationale for the use of a mixed methods framework in this study.

Defining mixed methods.

Mixed methods research is an approach to study design that combines both quantitative and

qualitative methodologies (Abbas Tashakkori & Teddlie, 1998). The intention of combining these
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 115

approaches to research is primarily to address the strengths and weaknesses of either method being

utilised alone. The framework underpinning the application of mixed methods relies on the

contention that researchers select the most appropriate method, or methods, to answer questions

posed by the research (Hadi, Alldred, Closs, & Briggs, 2013). Mixed methods research allows the

collection and interpretation of both quantitative and qualitative forms of data, allowing both to

inform the results of the study (Creswell, 2014).

Wisdom, Cavaleri, Onwiegbuzie and Green (2012) describe mixed methods as “ … a better

approach to research than either quantitative-only or qualitative-only methods when a single data

source is not sufficient to understand the topic, when results need additional explanation … or when

the complexity of research objectives are best addressed with multiple phases or types of data,” (p.

722). Mason (2006) expands on this explanation by describing mixed methods as a means to

encourage “outside the box” thinking, allowing research questions to be framed according to the

problem at hand rather than constrained by research questions. Due to the nature of existing studies

in dual diagnosis relying extensively on population data and prevalence rates, or being qualitatively

focussed on substance use, this definition of mixed methods has immense significance to the design

of this study.

Tashakkori and Teddlie (2010) describe a number of core characteristics specific to mixed

methods research. The first of these characteristics, methodological eclecticism, considers a diverse

number of methodological tools available in mixed methods research to solve everyday problems.

Another core characteristic, the emphasis on a continuum rather than dichotomies, extends the

initial core characteristic by proposing that research should not be limited to an “either or,” being

quantitative or qualitative, instead “ … being replaced by a continua of options that stretch across

both methodological and philosophical dimensions,” (p. 274). The sentiment of recognising the

utility of a number of research tools is echoed in the third core characteristic, paradigm pluralism,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 116

whereby the acceptance of the existence of multiple paradigms is pivotal to mixed methods

research. Again, the characteristic of emphasis on diversity at all levels of the research enterprise

accedes to the notion of multiple paradigms, by recognising the variety of research methods

available and through another characteristic, focus on the research question in determining

methodological choice, indicating that all research designs should be considered in respect of the

problem at hand.

A brief history of mixed methods.

The introduction of the concept of mixed methods research is credited to Jick, who

described this methodology in 1979 as a means to seek convergence across quantitative and

qualitative research in the social sciences (Östlund, Kidd, Wengström, & Rowa-Dewar, 2011). In

terms of healthcare research, mixed methods research also served to exploit the strengths of both

quantitative research (generalisability and the ability to address a wide range of clinical issues) and

qualitative (the subjective experience and recognition of consumer centred healthcare) (Hadi et al.,

2013). The twenty years following the initial description of mixed methods saw philosophical

debate and refinement of the approach, as well as expansion into a number of varied disciplines

(Creswell, 2014). The key philosophy of mixed methods research throughout this time was that the

“ … underlying logic of mixing [methods] is that neither quantitative nor qualitative methods are

sufficient in themselves to capture the trends and details of the situation,” (Creswell, 2004, p. 7).

The subsequent expansion and interest in mixed methods studies is attributed to a shift away

from theoretically driven research to studies that are cost-effective and tailored to the needs of both

practitioners and policymakers (Östlund et al., 2011). Mixed methods designs have gained traction

in the contemporary research arena due to key advantages, such as providing narrative voice to

quantitative exploration and experimentation, bringing clinical research from the realm of pure

statistical enquiry to a more humanistic and consumer centred approach (Bilinski, Duggleby, &
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 117

Rennie, 2013). These attributes have resulted in an increase in popularity in the use of mixed

methodology designs in mental health research studies (Kettles, Creswell, & Zhang, 2011).

The explanatory sequential design.

A number of contemporary approaches to mixed methods research are identified in the

literature to date (Hadi et al., 2013). The approach utilised in this study is the explanatory sequential

design and is illustrated graphically in Figure 3. This design is a non-experimental approach to

exploring the research topic through a number of methodological phases and is characterised by the

initial collection of quantitative data, followed with qualitative data. The rationale behind this

method is to use the qualitative findings to give meaning to the initial quantitative data (Carr, 2009).

In terms of this study, the explanatory sequential design provides a prevalence rate for consumers of

MAPS in the initial quantitative phase, then following with qualitative exploration of the

experiences of consumers with dual diagnosis and clinicians who care for them allows the study to

comprehensively explore the issue of dual diagnosis in older adults.

Figure 3. Mixed methods study flow.

Traditionally, the explanatory sequential design is a two-phase model. However, during

literature searches around the topic of dual diagnosis in older adults, it became apparent that

clinicians played a substantive role in the care and management of these individuals. Therefore, a

decision was made to include a third phase of qualitative enquiry. This decision was also guided by

the results of the quantitative phase, which indicated a distinct possibility of under-diagnosis of
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AOD use disorders in the MAPS population. This decision follows one of the fundamental concepts

of the explanatory sequential design, which is to build the qualitative phase from the quantitative

results (Creswell, 2014).

Rationale for the use of a Mixed Methods Design.

The rationale for the use of a mixed methods design in this study related to the need to find a

research methodology appropriate to address the research questions. As mentioned in the literature

review chapter of this thesis, a number of studies regarding dual diagnosis, or substance use

disorders alone, in older adults are focussed on population prevalence. To replicate a quantitative

study locally to determine population prevalence of dual diagnosis in those over 65 was felt to have

little benefit to MAPS. Likewise, employing qualitative methodology alone would illuminate the

experiences of consumers with dual diagnosis and the clinicians who care for them, however the

question of just how many individuals with substance use disorders were presenting to MAPS

would remain.

Kettles, Cresswell and Zhang (2011) state that mixed methods is preferred to explain

quantitative results with the words of research participants. Further, they indicate that mixed

methods are preferred when one research method is inadequate by itself, as demonstrated above. In

the context of this research study, a percentile figure of prevalence of dual diagnosis defines the

existence of a problem, however it does not further explore the problem. Therefore, the decision

was made to include the perspectives of individuals with dual diagnosis to illuminate the situation at

hand. As the literature review progressed, it also became apparent that clinicians played a

substantive role in both the care of individuals with dual diagnosis, and as a barrier to service

provision (Croton, 2005; Staiger et al., 2011). Hence, a third phase of the research was added to

explore this issue.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 119

Using a purely quantitative or qualitative methodology alone failed to provide a

comprehensive approach to answering the research questions posed in the introductory chapter of

this thesis. Individuals with dual diagnosis present as a diverse population, and while a number of

quantitative studies have provided valuable insights into the problem of dual diagnosis, qualitative

research is the only methodology that allows the nuances of dual diagnosis to be explored fully,

even when the limitations regarding an inability to generalise results to a wider population are

considered. Perhaps one of the greatest examples of studies that have informed drug and alcohol

research include Faupel’s (1991) Shooting Dope: Career Patterns of Hard-Core Heroin Users,

which documented interviews with heroin users in the United States, and identified the notion of

dynamic usage careers, which are difficult to measure using quantitative methods. Similarly, Preble

and Casey’s (1969) early qualitative work demonstrated the nuances of the New York City heroin

market of the time, informed by interviews with inpatients at a Drug Addiction Unit.

A mixed methods approach was also favoured to involve active participants in MAPS, being

consumers and clinicians, as agents of change. Through involving both parties in a research process

it was envisaged that both camps would “own” the recommendations they made. Consumer

participants were provided with an opportunity to anonymously identify service deficiencies, while

clinicians were able to explore the nuances of caring for one of the most complex and difficult

subsets of clients in the mental health system today. Quantitative survey data, while allowing

generalisation of these findings, would sacrifice the depth required to bring this level of detail to the

findings and recommendations presented in the penultimate chapter of this thesis (Mason, 2006).

The advantages of using a qualitative approach to investigate this population does not

dismiss the utility of quantitative data. The initial stage of the project uses a quantitative file audit to

demonstrate the prevalence of dual diagnosis within MAPS. By performing this as the initial data

collection stage, the research ascribes to the explanatory sequential approach (Hadi et al., 2013).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 120

This method is described as prioritising quantitative research, then using subsequent qualitative

approaches to explain the findings of the initial quantitative stage (Creswell, 2004).

A final rationale for the use of a mixed methods design is that of data triangulation. Patton

(2002) describes data triangulation as a process whereby a number of approaches to investigation

are employed to strengthen a study. Triangulation recognises that each method has advantages and

disadvantages, and by combining methods with these strengths and limitations in mind, a more

thorough exploration of the topic at hand is achieved. In this study, data has been examined from

three distinct sources, providing divergent perspectives to the phenomenon of dual diagnosis in

older adults.

Phase One

The first study phase sought to determine the prevalence of dual diagnosis in older adults

assessed and case managed by the Caulfield Hospital MAPS. This phase of the research, in line

with the principles of the explanatory sequential design, was the initial data collection activity of

this study, conducted June 2014.

Description.
The initial phase of this research sought to answer the first research question, being: Does

the Caulfield Hospital Mobile Aged Psychiatry Service care for a significant dual diagnosis

population? To answer this question, a file audit was conducted, examining admission and

assessment data from June 2012-June 2014. Files were identified spanning a two-year period

immediately prior to the commencement of the file audit. Open cases (n=93) from the

commencement date were included in order to include clients with open episodes prior to June

2012. These clients were included as they were actively being case managed at the time of the file
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 121

audit, and specific details of their assessment date are discussed in Chapter Five. In total, the

number of records meeting the criteria for audit was 593.

The population for the initial phase of the project was individuals admitted to MAPS, with a

hospital identification number and electronic file created, residing in the geographical area

described earlier in this chapter. In essence, this indicated that a MAPS clinician had performed an

intake assessment on the individual, comprising a number of risk screening and history questions,

including the presence or absence of alcohol and other drug use. The majority of cases included in

the audit were over 65, however a small number of cases were aged in their early 60s, or in extreme

cases their 50s. These outliers were included as they were assessed or case managed in line with

MAPS policy of accepting referrals for early onset dementia or taking client care over from the

adult community care teams as they neared the qualifying age of 65 in times of low referral rates.

Inclusion and exclusion criteria.

The inclusion criteria for the initial phase of the study were clients assessed, case managed

or admitted to MAPS within the specified timeframe (June 2012-June 2014). There were no specific

exclusion criteria.

Method.

A list of admissions from the statewide Client Management Interface (CMI) computer

program was generated for the June 2012-June 2014 period, with individual electronic assessment

documents examined in the PowerChart medical records system. Files were first screened to

identify the type of data available. MAPS clinicians complete an initial assessment document when

first assessing referred individuals, that captures a range of information, including medical and

psychiatric history, medications, mental state examination, cognition and risk assessment. The
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 122

assessment document also contains a section on alcohol and other drug use, however this was

limited to describing risk in relation to current use, history and access to substances or substance

using networks in addition to a simple yes or no question for current AOD use. A text box is

provided for clinicians to enter narrative notes regarding current or historical patterns of

consumption.

Data was recorded manually onto the paper file audit tool. Narrative on assessments was

examined to determine whether alcohol or other drug use had been recorded. Brief notes were

recorded in the section provided on the file audit tool. Once the manual audit process was

completed, data was entered into SPSS version 21 for analysis.

Development of the audit tool.

A file audit tool was developed in order to allow data to be collected in a systematic fashion.

This tool was guided by the principles of clinical audit. Clinical audit is reported to have been used

historically as a tool to monitor morbidity and mortality, however is best defined as a quality

improvement methodology that seeks to improve outcomes in the care provided by individuals by

systematically reviewing care against a predefined set of criteria (Travaglia & Debono, 2009).

Although a recent Cochrane systematic review identified marginal benefit of using clinical audit as

a feedback tool, it was indicated that “ … audit is commonly used in the context of governance and

essential to measure practice [and] to know when efforts to change practice are needed,” (Ivers et

al., 2012, p. 13). This statement provided strong justification for using a file audit methodology to

answer the initial research question of this study.

The audit tool was adapted from a tool used by the Department of Human Services,

Victoria, to audit client files. Modifications were made to attain the correct data to be measured.

These tools were developed for use by independent auditors, and as such, have been subject to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 123

rigorous review and utilisation in a legislated setting (Department of Human Services, 2011). The

resultant tool was developed to gather basic demographic data (age, sex, suburb of residence, date

of assessment), and health data (mental health diagnosis, diagnosed medical conditions). An

additional section of the tool sought to determine whether a “yes” response was recorded in the

electronic assessment document in the alcohol and other drug use section. A section was added to

record a substance (if identified), and to record examination of narrative provided in the electronic

assessment document.

Reliability and validity.

Quantitative research relies heavily on the concept of rigour to achieve results that are both

reliable and valid. Reliability is defined as the ability of an instrument to be interpreted consistently

across situations, and validity as the ability of the instrument to measure what is proposed (Field,

2012). In order for the initial phase of this research project to be rigorous, the developed file audit

tool was required to meet the criteria of validity. Determining what the file audit tool was required

to collect and incorporating these requirements into the framework of an established file audit tool

accomplished this. The established tool used to base this instrument on was one devised by the

Department of Human Services for external auditing of disability services (Department of Human

Services, 2011).

Items measured by the audit tool included simple demographic information, such as age, sex

and suburb of residence, along with the presence of alcohol or other drug use, a primary mental

health diagnosis and concurrent medical conditions. Recording of co-occurring alcohol or other

drug use was limited to recording yes or no, as the computerised file auditing system only allows a

yes or no entry by clinicians. The electronic system also provides the ability for clinicians to enter

narrative notes for assessments. To ensure reliability, only the result of the yes or no entry was

recorded. No inference of alcohol or other drug use was used to record a positive result on the file-
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 124

auditing tool. During the process of auditing it became apparent that a number of assessments were

recorded as ‘false’ negatives, with narrative indicating that problematic alcohol or other drug use

was present. These instances were recorded as negative to preserve reliability, with written narrative

collected for later qualitative analysis. All file auditing was conducted by one researcher, ensuring

consistency in data collection techniques.

Data analysis.

As previously mentioned, data was entered into the SPSS version 21 computer program for

statistical analysis. Notes recorded from the analysis of recorded assessment narrative were

recorded in NVivo qualitative data analysis software for assessment. Quantitative analysis included

descriptive and inferential statistics and comparisons of the dual diagnosis and non dual diagnosis

group. The results of this analysis are detailed in the next chapter of this thesis.

Clinicians were able to enter text regarding the assessment as notes on the electronic record.

A qualitative analysis of these notes was conducted to determine documented alcohol or other drug

use, particularly where a “no” was recorded in the checkbox. The decision to analyse these

narratives in this fashion was made as they were considered to illustrate a number of failings in the

assessment process. The results of this analysis are also discussed further in Chapter Five.

Phase Two

The second study phase interviewed consumers of MAPS with dual diagnosis to explore

their experiences and thoughts on both their care and living with comorbid substance use disorder.

The recruitment and interviews for this phase took place July 2014 - October 2014.
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Description.

This phase of the study employed semi-structured interviews with existing clients of MAPS

who have been identified by their case manager as having co-occurring substance use disorder. This

phase was considered important in order to add a qualitative “voice” to the data obtained through

the initial file audit process (Jack, 2010) ; accordingly, a diverse spectrum of individuals were

interviewed, particularly in respect of the substances they used. The need to add qualitative data

was primarily required to address a substantive gap in contemporary literature, as studies

interviewing older adults with dual diagnosis simply do not exist in the Australian context.

Sampling process.

Patton’s (2002) deviant, or extreme case sampling was selected as the sampling

methodology for this phase of the study. Deviant sampling is described by Patton as a “ … strategy

[involving] selecting cases that are information rich because they are unusual or special in some

way,” (p. 231). Seawright and Gerring (2008) argue that this sampling methodology is more

appropriate than randomised sampling in small population studies, allowing the selection of cases

that are representative of the population characteristics to be studied. Teddlie and Yu (2007) explain

that “ … deviant cases provide interesting contrasts with other cases, thereby allowing for

comparability across those cases,” (p. 81). Teddlie and Yu describe the process of deviant sampling

as determining a dimension of interest and then locating extreme cases in that distribution. In

respect of this study, extreme cases were identified by case managers of MAPS, who were asked to

identify dual diagnosis consumers of the service that they found to be complex or challenging in

their presentation.

The rationale for asking case managers to effectively identify a sample to approach for

interviewing follows the principles of deviant case sampling, in that “extreme” cases are identified
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 126

as examined in order to provide insights into the population (Draucker, Martsolf, Ross, & Rusk,

2007). Individuals identified by case managers to participate in the second phase of the research

typically had long substance use histories, severe mental illness and a history of involvement with

mental health services. Most continued to use substances, however a small number had adapted

their substance use as they grew older.

Potential participants were discussed at a weekly clinical review meeting, where all

members of the MAPS multidisciplinary team were present, including the consultant psychiatrist

and psychologist. The decision to discuss participants at the weekly clinical review meeting allowed

any concerns regarding the ability to participate to be aired, as well as providing the means to

discuss contingency regarding any adverse outcomes if they were to arise.

Inclusion/exclusion criteria.

Inclusion criteria for this phase of the study was as follows:

a. Clients currently managed by MAPS;

b. With an identified co-occurring substance use disorder;

c. And, willing to voluntarily participate in a recorded interview.

Exclusion criteria was designed to exclude those who may be unable to provide valid

consent due to cognitive impairment:

a. Mini Mental State Examinination (MMSE) score lower than 24 on last assessment

by a MAPS or Alfred Health staff member;

b. Individuals with a DSM-V diagnosis solely in the family of tobacco-related disorders

as their only substance use disorder (American Psychiatric Association, 2013);

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 127

c. And, those individuals currently on a Guardianship Order through the Victorian

Civil Appeals Tribunal (VCAT) or any other court.

Method.

For the interviews conducted for this phase, 11 potential participants were approached with

an invitation to participate in the study. This involved the provision of a flyer through their case

manager, and if the participant expressed interest in participating in the research project, was

approached by the researcher to provide a plain language statement for the study. The researcher, if

requested by the potential participant, provided verbal explanation of the plain language statement.

Interviews took place in the participant's home; each participant was given the option of the

interview taking place at the MAPS clinic or at their residence, with all expressing a preference to

be interviewed at home. Interviews lasted from approximately 55 minutes to 1 hour 30 minutes.

Participants were reminded they could terminate the interview at any time and specific consent was

sought to record each interview using a Philips portable digital voice recorder. All participants

consented to recording using the Philips portable voice recorder; upon completion of the interview,

audio files were transferred to computer, loaded into ExpressScribe software and transcribed by the

researcher into Microsoft Word. Participants were reimbursed $25 cash for their participation in

accordance with the approving health service policy.

Development of the semi-structured interview questions.

The semi-structured interview tool used in the second phase of the study was guided by the

literature review and initial phase of the study. The literature review indicated that older adults with

substance use disorders often had long “careers” of fluid use, moving in and out of substance use as

well as adapting their use as they aged (Best et al., 2010; Darke et al., 2009; Levy & Anderson,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 128

2005). Therefore, a number of questions were devised to explore histories of alcohol and other drug

use, in addition to determining involvement with mental health and substance use treatment

services. The initial phase of the research identified a distinct lack of treatment planning or

intention to refer to specialist drug and alcohol services in the assessment documentation. Questions

were included in the semi-structured interview tool to determine prior substance use treatment and

responsiveness to alcohol and other drug use by the service.

Although a number of questions did attempt to obtain specific information, the interview

was conducted to allow the participant to tell their story of living with dual diagnosis as best as

possible. To achieve this aim, basic counselling principles were applied, such as open ended

questioning, reflective and summarising statements in order to allow conversation to develop and

provide rich information (Martino et al., 2002).

Rigour.

Rigour is defined as a means of establishing competence and integrity in the research

process, and as mentioned in the previous section, relies on a number of factors to ensure research

meets accepted standards. As opposed to positivist methodologies, such as quantitative approaches,

reliability and validity are argued to be poor measures of rigour in naturalistic, qualitative studies

(Tobin & Begley, 2004). Four criteria are noted to be more suited to this type of enquiry, namely

credibility, dependability and conformability (Houghton, Casey, Shaw, & Murphy, 2013). Referring

to the value and believability of qualitative findings, credibility is enhanced by three factors:

prolonged observation, triangulation and peer debriefing (Polit & Beck, 2008).

In the context of this study, prolonged observation has taken place prior to the creation of

the research questions, through the researcher’s clinical work and reflection. Triangulation, being a

“merging” of data sources, is a natural element of mixed methods studies. This study involved
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triangulation through expanding the quantitative findings with qualitative analysis, with each phase

building on the results of the last (E. C. Carr, 2009). Peer debriefing, although a contentious topic in

qualitative paradigm discussion, involves examination of research findings by colleagues or

external experts, and was carried out both via the supervisory relationship inherent in higher

degrees by research studies, and through exposing the findings of the research to robust peer review

through conference presentations and journal articles (Taylor, 2013). This process occurred

concurrently while the research was conducted and is evidenced in the front matter of this thesis.

Houghton (2013) also discusses the use of an audit trail and reflexivity to achieve

dependability and conformability. Dependability is akin to reliability in quantitative research,

indicating “stability” of data, whereby conformability refers to the accuracy of the data (Rolfe,

2006). An audit trail was kept while conducting this research, allowing verification of the research

process. This audit trail includes raw research data, such as audio recordings, database files used in

the first phase of the research, and coding summaries created with the NVivo computer program.

These materials were stored for the time period specified in the Australian Code for Responsible

Research (National Health and Medical Research Council, 2007). Reflexivity refers to the

identification of the influence a researcher exerts over research findings and is aided by making

decisions transparent through keeping a log of decisions made when analysing findings and robust

coding strategies (Fereday & Muir-Cochrane, 2008). In the context of this study, notes relating to

coding decisions were kept within the NVivo computer program, with a thematic approach

employed while coding qualitative data (Polit & Beck, 2008).

Data analysis.

Once transcription was complete, written transcripts were loaded into NVivo qualitative

analysis software. Thematic analysis was conducted to determine the salient themes emerging from

the interview process. Thematic analysis is defined as the process of identifying and reporting
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 130

themes in data (Fereday & Muir-Cochrane, 2008). Key themes in the transcripts of the second phase

were identified using the process outlined by Braun and Clarke (2006):

Phase 1: familiarising yourself with your data

Phase 2: generating initial codes

Phase 3: searching for themes

Phase 4: reviewing themes

Phase 5: defining and naming themes

Phase 6: producing the report (pp. 87-93)

Aside from the aid of this step-by-step approach to data coding, concept mapping of themes

was also utilised in order to allow a comprehensive examination of the concepts emerging from the

data. The overarching content analysis process for the second and third phases of the study is shown

in Figure 4.

Figure 4- Braun and Clarke's (2006) coding flow as applied to phases two and three
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 131

Challenges of the second phase.

Rosen (2014) has conducted a number of studies with older adults who are enrolled in

methadone programs and describes this population as high risk due to illegal drug use and

vulnerability. In addition, access is often difficult with populations who use illicit substances due to

the fact that many drugs remain illegal under Australian law, and as a result, participating honestly

in a research study examining this very topic renders the possibility of prosecution (Faugier &

Sargeant, 1997). This was also a complexity for this study, with five participants who refused to

participate in the first and second rounds of the consumer interviews citing reasons such as not

wanting to relieve the trauma of long involvement with mental health services, not wishing to

disclose illicit substance use or believing they did not fit the participant profile of the plain language

statement as they did not consider their alcohol or drug use problematic.

Sandberg and Copes (2013) illustrate a number of issues in approaching participants who

use alcohol and other drugs, including assurances of confidentiality, and an ability to complete

interviews “on the spot” to avoid the risk of losing participants due to change of mind or a change

of circumstances. Ethics approval necessitated a lengthy plain language statement (see Appendix 2)

that, although comprehensive, provided a substantial barrier to participation. The plain language

statement required verbal explanation in all interviews, and often resulted in participants

questioning sections that mandated disclosure of illegal activities if required by law. The wording of

the plain language statement was taken from a Victorian Government Department of Health

document required as part of the ethics approval process. This section of the plain language

statement frequently unsettled consumers who used illicit substances, often requiring explanation

and reassurance by the researcher that data would be kept secure and not disclosed to the authorities

unless mandated by a court order.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 132

Interviewing “on the spot” was made difficult by the recruitment strategy approved by the

ethics committee, whereby an introduction with an individual’s case manager was performed prior

to them being approached for consent as a potential participant. This process often meant delays

between the initial provision of a plain language statement, a follow up telephone call by the

researcher, and a visit to further clarify the plain language statement and commence a recorded

interview.

Additionally, there was a danger of a dependent relationship between the researcher and

consumers previously case managed or assessed in the service. Fortunately, only one consumer had

a previous case management relationship with the researcher. In this case, the consent and interview

process were conducted by the senior supervisor of the research project. Transcription and coding

was discussed with the senior supervisor to ensure accuracy.

During the formulation of this research project, the initial proposal sought to interview

family, carers, significant others or residential facility staff as well as the consumer. Naturally, these

interviews would only take place if the consumer consented. This approach was intended to provide

a multidimensional view of dual diagnosis in older adults, particularly when living in residential

care facilities, where staff often feel challenged and unsure about the care they provide to this

cohort (Klein & Jess, 2002). Advice received prior to submission to the health service ethics

committee was that a separate consent process would be required, and would likely be rejected,

meaning the perspective of carers and family of many consumers was unable to be gathered during

this process.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 133

Phase Three

The third phase of the project utilised semi-structured interviews with clinicians from

MAPS in order to describe the experiences, attitudes and suggestions for service improvement in

the care provided to consumers with dual diagnosis.

Description.

As indicated in the literature review presented in Chapter Three, this phase was considered

essential to the project in order to determine the prevailing attitudes that clinicians held, and the

challenges encountered in caring for older individuals with dual diagnosis (Deans & Soar, 2005).

Croton’s (2005) identification of clinician and service attributes as barriers to service also justified a

qualitative exploration of clinicians providing care to older adults with dual diagnosis. In order to

explore these attributes, semi-structured interviews were considered the optimum method to both

allow clinicians to answer questions and examples posed to them, and to generate robust discussion

of the research problems at hand (Redmond & Curtis, 2009).

Sampling Process.

Sampling in this phase was limited to clinicians working within MAPS. At the time of

sampling (July 2015), clinicians in the case management stream of the service consisted of five

disciplines: six registered nurses, two occupational therapists, two social workers, one carer

consultant and one psychologist. Email invitations to participate were sent to a predetermined

MAPS staff list held by the parent health service. Attached to this email was a plain language

statement. Participants were encouraged to approach the researcher to discuss any questions around

participation and were asked to agree to participate via return email. Ten clinicians were

approached to participate in this phase of the research project, with all agreeing to take part in the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 134

interview process. Four were unable to be approached due to unplanned and extended leave from

MAPS at the time of the interview process (August 2015-September 2015).

Method.

Clinicians participating in the third phase of this research project were interviewed in the

MAPS office at a time that was convenient in terms of their workload. These interviews were

conducted in a semi-structured fashion. The semi-structured interview provided a number of

prompts exploring experiences of providing care to older adults with dual diagnosis, service

responses to dual diagnosis and suggestions for further improvement. The intention of the semi-

structured interview guide was to stimulate discussion around the topics being investigated during

the interview. The semi-structured interview guide in outlined in Appendix D.

A plain language statement was left with clinicians to peruse after initial verbal explanation

of the research process; further explanation of the plain language statement was offered if required.

The interview process mirrored that of the second phase, with all interviews recorded to a digital

voice recorder, transcribed and coded using the NVivo software program. All interviews were

approximately 30 minutes duration, following the semi-structured questionnaire document and

providing opportunity for clinicians to add their comments, experiences and thoughts on the

management of older adults with dual diagnosis in MAPS.

Development of the semi-structured interview questions.

The semi-structured interview tool was developed in order to raise concerns addressed by

consumers during the second phase of the study. Additionally, it sought to stimulate discussion

around the potential barriers to service provision (Croton, 2005) and explore any recommendations

for service improvement that clinicians had. To this end, this phase of the research sought to make
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 135

clinicians active participants in the research process, to share recommendations that contributed to

Chapter Nine of this thesis. In accordance with the second phase of this study, the semi-structured

tool sought to merely stimulate discussion rather than provide a rigid, prescriptive framework for

direct answers.

Rigour.

Processes to achieve rigour for the third phase of the research were identical to those

employed in phase two and are outlined in detail in the previous section.

Data Analysis.

Data analysis for this phase followed the framework outlined in phase two, including

transcription and analysis in NVivo qualitative software. The results of this process are presented in

Chapter Seven.

Ethical Considerations

Ethical approval for this project was sought from the Alfred Health Human Research Ethics

Committee. A number of concerns were raised during this process, including the aforementioned

issues with interviewing consumers, data security and the legal implications of discussing illicit

drug use with participants. After revisions to the satisfaction of the ethics committee, approval was

granted. The RMIT University College Human Ethics Advisory Network endorsed this approval.

Approval and endorsement documentation for this study is presented in Appendix A. This section

discusses the ethical considerations present in this research study and the measures taken to address

these issues.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 136

Vulnerable populations.

The participants of the second phase of this research are typically described as a “vulnerable

population.” Alexander (2010) discusses vulnerability as participation in research that involves a

sensitive topic, including participation by stigmatised individuals, involvement in illegal or deviant

activities and discussion of areas of life considered private or intimate. Further, Moore and Miller

(1999) propose the notion of “doubly vulnerable” populations, where a number of indicators of

vulnerability are combined. These indicators include mental illness, substance use, homelessness

and ageing. The second phase of this research involves research with individuals who, by this

definition, are doubly vulnerable.

Issues when considering a vulnerable research population include increased ethics scrutiny,

challenges in recruitment and obtaining informed consent. Additionally, accessing numbers suitable

to create an adequate research sample is a predominant concern, particularly given the challenges

confronting recruitment strategies (DiBartolo & McCrone, 2003). This research was by no means

immune from these challenges. Although the process to obtain ethics approval for this research

project was relatively uncomplicated, the contemporary literature indicates a “gatekeeping” role of

ethics committees, particularly where there is a perceived need to “…[shelter] from research that

might be insensitive, intrusive, or distressing,” (Walker & Read, 2011, p. 14). Conversely, Walker

and Read also propose that gatekeepers can be employed to help obtain a sample large enough to

complete the research study. This is evident in those with significant relationships with potential

participants, such as relatives or healthcare workers. In terms of this study, case managers from

MAPS were engaged to assist with recruitment, identifying consumers they felt were particularly

“tricky” in terms of their dual diagnosis.

Feedback from the ethics committee concerned, in part, the potential distress of participants

undertaking research in the form of interviews. This critique concerned asking participants about
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 137

their drug use and mental health service histories. A reasonable concern of this process was the risk

of creating emotional distress, and a comprehensive plan was developed for referral and additional

support if this occurred. However, research by Biddle et al (2013) indicates that individuals are

more likely to derive benefit from research participation than experience harm. Certainly, this was

reflected in the interviews conducted during the second phase, where no emotional distress was

experienced by any participant during this process.

Another concern raised by Zanjani and Rowles (2012) when researching sensitive topics is

that of instrumentation. Zanjani and Rowles indicate, “… individuals can be hesitant to provide

accurate and comprehensive detail about an issue they consider sensitive,” (p. 400). Certainly, this

was considered during the process of interviewing participants, both during the second and third

phases. Clinicians in the third phase may feel pressured to discuss an ideal of their practice rather

than the reality. Additionally, assessments conducted during the first phase rely heavily on self-

report of alcohol and other drug use. Measures to address this issue are discussed in each results

chapter.

Informed consent.

Booth (1999) describes issues in working with difficult to access populations, including

“Obtaining informed and conscious consent from people who are intoxicated or under the influence

of medication or other drugs. Consensual issues may be further complicated if the person… has a

mental illness,” (p. 78). As discussed in the previous section of this chapter, the participants in this

research study had a number of vulnerabilities: mental health problems, AOD use, ageing, chronic

medical conditions and often, poverty and marginalisation. McCrady and Bux (1999) interviewed

researchers examining substance users and found that issues arose when obtaining consent from

vulnerable populations, namely in the comprehension of consent. In this study, this issue was

addressed by the use of specific exclusion criteria to exclude potential participants who may have

capacity issues due to cognitive impairment, or subject to legal orders delegating their decision-
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 138

making powers to a guardian. The specific test to determine the effect of cognitive impairment was

the Mini Mental State Examination (MMSE), with a score of less than 24 indicating the onset of

clinically significant signs of cognitive impairment and a definitive point of exclusion (Tombaugh

& McIntyre, 1992). While protecting participants during the consent process, this exclusion

criterion had the effect of excluding individuals with dual diagnosis and cognitive impairment,

arguably a highly vulnerable and poorly researched population (Wu & Blazer, 2011).

Further, McCrady and Bux’s (1999) participants highlighted the importance of stressing that

participation would not affect treatment decisions and that participation remained voluntary. These

suggestions were incorporated in the plain language statement, and special emphasis was given to

these points when providing a verbal explanation by the researcher. Additionally, potential

participants were given the opportunity to spend time reading the plain language statement, or

seeking the input and advice of a relative, friend or health professional not involved with the study

to assist with explanation of the research and advice on whether to participate.

Payment for interview.

Payment for interview is somewhat controversial in contemporary discussion concerning

research with vulnerable populations. Some authors contend that financial compensation for

participation in research is an appropriate measure and validates the contribution made by

participants, while others argue that it amounts to coercion and encourages participation merely for

fiscal benefit (Sandberg & Copes, 2013). Vanderstaay (2005) describes ethnographic fieldwork

where the author explains that payment for participation led to a tragic chain of events, triggered by

the purchase of illicit substances with research payments, and leading to a participant being jailed

for murder. Although an extreme example, an ethical debate does exist around payment for

interview and enabling illegal behaviour by paying participants for their time.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 139

The health service ethics committee overseeing this research project mandates a policy that

all consumer participants in research undertaken by the health service are reimbursed a token

payment of $25. Fry and Dwyer (2001) found financial gain is a substantive reason for research

participation in an exploratory study of injecting drug users, also indicating that Australian research

guidelines at the time indicated that provision of financial incentive was tantamount to coercion and

a barrier to informed consent. Certainly, consumer participants in this study were grateful for

reimbursement for their time, which typically amounted to an hour, however most were

appreciative of the opportunity to tell their story and provide their feedback on service experiences.

This sentiment is echoed by the work of Alexander (2010) when interviewing palliative care

patients, who frequently reported the need to tell their story, and for their contribution to “help

someone.”

Fry and Dwyer (2001) also indicate that research participation is not merely driven by

economic incentive alone and involves a number of altruistic elements. These include involvement

in shaping policy, sharing experience and expertise, personal satisfaction and activism, validating

the argument that research payment is closely aligned to reimbursement for time of participation

and a recognition of the value of a participant’s contribution, rather than an impediment to

gathering consent.

Researcher safety.

An issue that arose while conducting consumer interviews involved interviewing in “unsafe”

locations. The Human Research Ethics Committee of the health service where this study was

conducted required extensive evidence of contingency plans when interviews potentially became

unsafe. Fortunately, this situation only occurred once when visiting a participant who had agreed to

participate at his residence at an agreed time. On arrival, five individuals were present and using

illegal substances, requiring a reschedule of the interview. The participant later confided that these
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 140

individuals frequently arrived at his residence uninvited, and if told to leave, would break his

windows and physically threaten him. Aside from this situation, interviews were sometimes

conducted in premises where illicit drugs were often used, leading to potential to be caught up in

Police investigation or be present when drug sellers, buyers or users arrived.

Parker and O’Reilly (2013) expand on these issues while discussing their experiences of

physical threats during a qualitative study, recommending a risk assessment of participants prior to

interviews, as well as specialised training in managing risk. Situational risk, as labelled by Bahn

(2012), includes threats of violence, verbal abuse from the participant as well as others who may be

present. Fortunately, this researcher had the opportunity to discuss potential issues with participants

with their mental health case managers and the multidisciplinary team prior to interviewing. Despite

the lack of training available in these situations for qualitative researchers, this researcher had

completed safety training as a community mental health nurse. However, this was by no means

considered to mitigate risk in any way, and as mentioned in the example earlier, if the situation was

deemed to be inappropriate or risky, the interview was rescheduled.

Devising a research safety protocol is considered to be a way to manage the risk of field-

based interviews conducted by lone researchers (Paterson, Gregory, & Thorne, 1999). Barr and

Welch (2012) expand on this idea, indicating that most ethics procedures are geared towards the

safety of participants rather than researchers. To this end, the authors identify another aspect of

safety when conducting qualitative field research of sensitive topics: psychological health. To

maintain the psychological health of this researcher, regular supervision meetings often served as

debriefing after field interviews, where transcripts and experience were discussed in depth.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 141

Summary

This chapter has provided a comprehensive overview of the research process undertaken to

address the research questions posed in the introductory chapter of this study. The explanatory

sequential approach, using three phases whereby each informs the next has been described in detail

in relation to each of the three phases of the study. These phases, being a quantitative file audit and

two semi-structured interview phases also have a number of ethical considerations that have been

described in this chapter. The next three chapters will outline the findings of each phase of the

research project in depth.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 142

Chapter Five

Phase One: Results of the File Audit Process

Introduction

This chapter presents the results of the first phase of the research project: a file audit of

assessments and admissions to MAPS over a two-year period, June 2012-2014. The file audit aimed

to determine the prevalence of dual diagnosis within MAPS. In addition, it also collected basic

demographic and descriptive data of the sample, as well as allowing a review process of the

electronic file notes entered by clinicians performing assessments. This review highlighted a

number of systematic issues with the assessment process; these issues will be discussed separately

later in this chapter.

The file audit process required cross-checking of electronic records from a computer-

generated spreadsheet of eligible consumers to the electronic records program followed by manual

review of summary file notes contained within the system. This process took approximately 50

hours to complete, requiring access to an electronic system of consumer files. Upon completion,

data was entered into SPSS version 22 for statistical analysis, allowing demographic information to

be summarised and descriptive statistics to be presented in this chapter. The study process is

displayed graphically in Figure 4.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 143

Figure 5. Flowchart of Phase One study process.

Descriptive Statistics of the Sample

The audit identified a total of 593 individual assessments for a two-year period spanning

June 2012 - June 2014. Summary descriptive statistics for the sample are shown in Table 1. The

total sample had a mean age of 78.24 (SD=9.76). The cohort comprised 263 males (44.4%) and 330

females (55.6%), predominantly referred to MAPS for a diagnosis of depression (25.8%), with

behavioural and psychological symptoms of dementia (24.3%) and mental state for assessment
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 144

(undefined diagnosis, 19.6%) ranking second and third respectively. The chief suburb of residence

of individuals assessed was Caulfield (14%), followed by St Kilda (9.1%). Figure 5 shows suburb

of residence graphically. These results may be explained by the large proportion of nursing homes

in Caulfield (including on the Caulfield Hospital campus, home to the MAPS office), however this

figure also indicates the publicly funded nature of the MAPS service. Suburbs with little

representation have a higher median house price, higher mean household income and a smaller

proportion of both public housing and boarding house accommodation (Birrell et al., 2012). This

may suggest an entirely separate older dual diagnosis population being managed by the private

healthcare sector. This is discussed further in chapter eight of this thesis.

Gender of consumer

Male Female

Std Std
Mean Number Mean Number
Dev Dev

Age of consumer 77 9 80 10

Schizophrenia 36 52

Schizoaffective Disorder 20 15

Bipolar Affective Disorder 24 28

Depression 60 93

Diagnosis of Behavioural and Psychological

61 83
consumer Symptoms of Dementia

Personality Disorder 0 4

Mental State for Assessment

62 54
(Undefined)

Eating Disorder 0 1

Table 1. Summary descriptive statistics of the sample.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 145

Figure 6. Suburbs of residence for the sample.

Of the total sample, 92 individuals (15.5%) were recorded to have co-occurring alcohol and

other drug use on assessment. Age outliers (under 65 years old) represented in the data relate to

individuals assessed in the hospital by MAPS consultation-liaison staff, or individuals accepted by

the service due to age related conditions or early handover from adult community mental health

services. A number of individuals 100 years of age and over were also assessed during the specified

time period. Outliers also exist geographically, and result from individuals assessed “out of area,”

whereby they are admitted to a neighbouring mental health service due to capacity issues in the

parent service.

The Dual Diagnosis Group

The following section describes the characteristics of the dual diagnosis group, being

individuals who were identified in the assessment process as having co-occurring alcohol and other
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 146

drug use. The following sections describe the statistical processes used to analyse the dual diagnosis

group and their results.

Gender.

Examination of the dual diagnosis group indicated that this group were more likely to be

male (n=60, 65.2% of the group) than female (n=32, 34.8% of the group). Pearson’s chi-square

analysis revealed a significant association between gender and alcohol and other drug use (𝜒2(1) =

19.21, p=<0.001). Odds ratio analysis was calculated, and based on the result, the odds of males

using alcohol and other drugs were 5.45 times higher than females. Assumptions of this analysis are

that the self-report of individuals using alcohol and other drugs is accurate. This limitation is

discussed later in this chapter.

Age.

Consumers in the dual diagnosis group were younger (mean 72.82, SD 8.318) than those

who did not use alcohol and other drugs (mean 79.24, SD 9.682). An independent samples t-test

was conducted, identifying a statistically significant difference (t (-6.629), 95% CI [-8.340, -4.508],

p=<0.001). When comparing the age distribution graphically, a box plot (Figure 6) of both age

groups demonstrates a lower median age and a narrower range than those who were not identified

as using alcohol and other drugs. Outliers in the “yes to AOD” column of the box plot are younger

individuals assessed in Caulfield Hospital by a consultation-liaison psychiatry service run by

MAPS.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 147

Figure 7. Boxplot of age, grouped by AOD use status.

Substances used.

Alcohol was the most commonly used substance in the dual diagnosis group as illustrated in

Figure 7. This histogram demonstrates that alcohol is the predominant substance used by older

adults assessed by MAPS. However, further analysis based on gender indicates that males are more

likely to use alcohol, while female consumers had a more equal distribution of substances in

addition to alcohol, including benzodiazepines and opiates, as indicated by the histogram in Figure

8.

Fisher’s exact test found a statistically significant association between gender and type of

substance used (41, p=<0.001). Of note is that the total of benzodiazepine and opiate using females

were almost equal to alcohol drinkers (11 versus 13), whereby male alcohol drinkers (n=52)
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 148

dwarfed all other categories. The closest male category was polysubstance use of alcohol, cannabis

and another drug (n=3).

Figure 8. Substances recorded in assessment documentation.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 149

Figure 9. Substances recorded grouped by gender.

Mental health diagnosis.

The dual diagnosis group reveals depression as the most common diagnosis in this cohort.

This result is in line with Coulson et al (2014), and the descriptive study performed by Chaput,

Beaulieu, Paradis and Labonte (2011) which both show a high degree of affective disorders in older

adults who use alcohol. In contrast, the non-dual diagnosis group predominantly showed

behavioural signs and symptoms of dementia as the primary diagnosis, possibly reflecting the role

of a nurse practitioner program specialising in this area in MAPS. The differences between primary

diagnosis in each cohort are illustrated visually in Figure 9.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 150

Figure 10. Mental health diagnoses in both cohorts.

A chi square test of association was performed, finding a significant association between

dual diagnosis status and mental health diagnosis (𝜒2(1) = 30.353, p=<0.001), suggesting that

depression is the most common mental health diagnosis in dual diagnosis presentations to MAPS.

Comorbid health conditions.

Comorbid health conditions were prevalent for both dual diagnosis and non-dual diagnosis

groups, indicating a degree of medical complexity inherent in the older adult mental health

population presenting to MAPS. Given the wide spectrum of medical conditions indicated in

assessment documentation, conditions were clustered into systems: neurological (such as stroke,

acquired brain injury and the dementias), cardiovascular (including hypertension, prior acute

myocardial infarction and heart disease), respiratory (chronic obstructive airways disease, asthma),
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 151

musculoskeletal (primarily osteoarthritis), endocrine (primarily diabetes), gastrointestinal (such as

gastro-oesophageal reflux disease) and any cancers. Individuals were marked positive to each

category if any medical conditions were listed in their assessment documentation. Figure 11

demonstrates the percentages of individuals with medical conditions in each category, divided into

gender and dual diagnosis/non-dual diagnosis status. Percentages represent proportions of both the

dual diagnosis group (n=92) and non-dual diagnosis group (n=501) respectively.

Musculoskeletal disorders

Gastrointestinal disorders
Cardiovascular disorders
Neurological disorders

Respiratory disorders

Endocrine disorders

Cancers
Male

dual 28.3% 27.2% 17.4% 5.4% 10.9% 6.5% 6.5%

diagnosis

Male

non-dual 17.2% 25.1% 7% 7% 9.2% 6.4% 4.4%

diagnosis

Female

dual 10.9% 15.2% 7.6% 3.3% 5.4% 6.5% 7.6%

diagnosis

Female

non-dual 22.4% 34.5% 8.2% 15.8% 18.4% 8.6% 7.6%

diagnosis

Table 2. Medical conditions grouped by dual diagnosis status and gender.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 152

Pearson’s chi square test was conducted to determine potential associations between gender

and dual diagnosis status. The split file command in SPSS version 22 was utilised to order cases by

a positive indication to alcohol and other drug use prior to performing statistical testing. A

statistically significant association was found between female gender and musculoskeletal condition

in the non-dual diagnosis group (𝜒2(1) = 5.902, p=0.015), in addition to female gender and

endocrine disorders (𝜒2(1) = 4.080, p=0.043). No statistically significant associations between

gender and medical conditions were found in the dual diagnosis group.

Similarly, Pearson’s chi square test was used to determine potential associations between

dual diagnosis status and medical conditions. This testing found mixed results, with statistical

significance suggesting associations between the non-dual diagnosis group and cardiovascular

conditions (𝜒2(1) = 9.479, p=0.003), musculoskeletal conditions (𝜒2(1) = 9.402, p=0.003) and

endocrine disorders (𝜒2(1) = 5.130, p=0.027). Likewise, a statistically significant association was

found between respiratory conditions (𝜒2(1) = 5.401, p=0.023) and dual diagnosis status.

Qualitative Analysis of the Assessment Process

Qualitative analysis of the assessment process was primarily conducted to determine

whether file notes entered into the electronic assessment document indicated AOD use without a

“yes” recorded in the AOD use section. Analysis of the notes also allowed examination of the

assessment processes and demonstrated a number of substantial shortfalls. While examining

assessment documentation, notes were entered alongside the collected demographic details on the

SPSS dataset. These notes were condensed accounts of the file notes presented in the electronic

assessment document. This section identifies the issues arising from the analysis of the summary

file notes examined during the file audit process.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 153

Lack of documentation.

Some assessment documents suffered from a lack of documentation regarding AOD use, as

evidenced by the two consumers who were recorded as “yes” to AOD use without any substance

being recorded in the assessment document. Additionally, a number of consumers were recorded

with substance use, however poor and ambiguous documentation of usage patterns and history was

present:

Pethidine - past history not specified (case number 406).

Drinks beer on a daily basis. Not quantified further (case number 455).

Increased consumption - not specified in units (case number 20).

Daily alcohol not quantified. Alcohol related acquired brain injury (case number 173).

Poor quantification and exploration of substance use history is in contradiction to best

practice of substance use assessment, where a comprehensive screening and history-taking process

guides treatment decisions in both the AOD and mental health realms (Mohlman et al., 2012;

Pennington, Butler, & Eagger, 2000). It also demonstrates that sufficient importance was not given

to a correct account of AOD use during the initial assessment. A lack of consideration of AOD

within mental health clinical assessment was addressed in the Victorian State Government’s Dual

diagnosis: Key directions and priorities for service development document (2007). This document

identified a service outcome whereby “… intake and assessment approaches … promote integrated

dual diagnosis treatment and recovery programs as core aspects of service,” (p. 24), however this

finding illustrates that this service outcome is not being met.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 154

There was also inadequate exploration or documentation of the consumer’s use of AOD in

response to mental health symptoms, and/or the impact substance use has on an individual’s mental

state. In this example, anxiety is the focus but the co-existing problem of increased alcohol

consumption is not further quantified:

Increased [alcohol use] in the context of anxiety, usage not quantified (case number 320).

Poor understanding of alcohol guidelines.

An additional issue arising from a lack of documentation is the apparent poor understanding

of current Australian Government guidelines for safe alcohol consumption. These guidelines

indicate that for prevention of long-term health impacts, no more than two standard drinks should

be consumed daily; for the prevention of injury related to alcohol use, no more than four standard

drinks should be consumed in one episode (National Health and Medical Research Council, 2009).

Two assessments recorded AOD use as “no” while indicating that an individual was consuming

beyond these guidelines, as indicated by the following examples:

Reports 2 glasses of wine nightly (case number 69).

2-3 glasses of wine daily (case number 45).

Although this use of alcohol can be categorised as sub-threshold when referring to

traditional definitions of alcohol abuse and dependence, it remains problematic in respect of

documented long-term health risks. Failing to identify this level of drinking as risky also eliminates

the opportunity to provide brief interventions and feedback around drinking levels, a strategy that

has proven useful in reducing drinking levels in the older adult population (Schonfeld et al., 2010).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 155

Another problem inherent in poor understanding of alcohol consumption guidelines was a

failure to quantify drinking vessel size, particularly given the research demonstrating over pouring

in older adult populations (Wilkinson, Allsop, & Chikritzhs, 2011). Safe consumption guidelines

are based on the notion of a standard drink, which is a predetermined measure of various types of

alcohol, each containing 10 grams of alcohol. Assessment documentation was absent in discussing

any attempts to determine drinking vessel size when exploring alcohol consumption.

Referral for AOD treatment.

Consideration of referral for ongoing AOD treatment at the time of assessment is pivotal in

addressing co-occurring disorders (D’Onofrio & Degutis, 2010; Mcinnes & Powell, 1994). Even in

the assessment documents with positive recordings for AOD use, no notes were found indicating

intent or recommendation for referral to specialist AOD treatment services. At times, prior AOD

treatment was noted, such as:

Current fortnightly 6-8 cans alcohol, history heroin, prescription painkiller, heavy THC and methamphetamine.

Rehab admission 2008 (case number 521).

In spite of prior AOD treatment becoming part of the assessment process, it was not

considered as a future option in all 92 of the individuals who recorded positive for AOD use.

Potentially, AOD treatment options were explored later during the case management process,

however this is at odds with current research suggesting that integrated treatment planning for

substance use disorders should occur during the assessment and screening process (Substance

Abuse and Mental Health Services Administration, 2013). Four examples of other assessments

documenting prior treatment encounters specifically with AOD services are:

Long history with multiple rehab admissions (case number 72).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 156

10-20 units [alcohol] a day. 2 prior detox admissions (case number 101).

Amount not quantified. Detox admission - claims recent abstinence (case number 132).

Longstanding [alcohol use] since early 20s, multiple detox and rehab admissions (case number 273).

Summary

The initial phase of the project demonstrates a small but substantial older adult dual

diagnosis population cared for by MAPS. However, the results are also limited due to the absence

of a formal screening process for alcohol and other drug use, as will be discussed later in this thesis.

This chapter has provided a comprehensive overview of the demographic characteristics of the

study sample, in addition to illustrating the prevalence and morphology of AOD use in older adults

presenting to the Caulfield Hospital MAPS. It also addresses the first research question guiding this

project, “Does the Caulfield Hospital Mobile Aged Psychiatry Service care for a significant dual

diagnosis population?” The implications of these findings will be discussed further in Chapter

Eight. The next chapter discusses the second phase of the research project, being the exploration of

the experiences of service users with dual diagnosis.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 157

Chapter Six

Phase Two: Findings from In-Depth Client Analysis and Interview

Introduction

This chapter presents the findings of the second phase of this study, which aims to explore

the experiences of consumers with co-occurring mental illness and substance use disorders. Six

participants agreed to participate in a semi-structured interview process, and after being identified

by their case managers, were provided with a detailed plain language statement and verbal

explanation if required prior to consenting to the process of interview. All six participants have had

mental health care provided to them by the Caulfield Hospital MAPS.

Several key themes emerged throughout the interview process, mirroring the notion of dual

diagnosis being a complex phenomenon involving a number of interrelated factors (Weiss, Mirin, &

Frances, 1992). The interviews conducted also demonstrate the challenges inherent in providing

care to this cohort, with the participants frequently describing their experiences with services as

being fraught with difficulty. These issues will be illustrated in greater detail throughout this

chapter.

The Second Phase

As indicated in Chapter Four of this thesis, this research project was conducted under and

explanatory sequential framework, whereby each phase informs the next (Stange, Miller, Crabtree,

O'Connor, & Zyzanski, 1994). The second phase of this study was informed by the first by drawing

questions from the initial file audit phase of the study: how did older adults come to be assessed by

MAPS? What substances were they using? What were their experiences of both having a dual
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 158

diagnosis and the care provided to them? This chapter reinforces the conclusions evident in the

previous chapter, such as a small, complex, difficult to assess population, particularly given the

difficulties in approaching and recruiting individuals to participate in such a project.

More specifically, analysis of the qualitative data was performed using the qualitative

descriptive methods outlined by Sandelowski (2000). Sandelowski described this method of data

analysis as “[entailing] an interpretation that is low-interference, or likely to result in easier

consensus among researchers,” (p. 335). As discussed in Chapter Four, this methodology allowed a

‘pure’ presentation of the findings of the interview process, free of the interpretations applied with

other qualitative frameworks. This step was considered necessary given the dearth of qualitative

research conducted with any cohort of older adults with dual diagnosis, and a desire to allow this

exploratory work to harness the voices of the participants in a form as close as possible to their

intended meaning (Sandelowski & Barroso, 2002).

The individuals who agreed to participate in this research project represent a broad spectrum

of substances used, mental health problems, social settings and experiences with treatment services.

Each participant’s history is summarised in the following section.

Participant Background

This section intends to provide a brief clinical synopsis of the participants who agreed to

participate in this phase of the project, both in order to provide context to the qualitative analysis

that follows and to illustrate the diverse presentations of older adults with dual diagnosis. The

clinical data presented was drawn from clinical histories stored on the electronic medical record

system at the time of interview, and each participant agreed to this process per the plain language

statement and consent form provided prior to interview. Despite the recruitment difficulties

discussed in Chapter Four, the participants represent a mixed range of mental health diagnoses,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 159

substance of choice, social circumstances and life events leading to the narratives they provided for

this research project. As such, they represent a broad spectrum of consumers of dual diagnosis older

adults who utilise mental health services.

Participant one.

Participant one was a 72-year-old female, residing alone in Government housing with

financial support from the aged pension. Participant one has three daughters who she has

intermittent social contact with and regular telephone contact. She has a medical history of chronic

obstructive airways disease (COAD) caused by cigarette smoking, with frequent hospital

admissions for infective exacerbations. Participant one also has hepatitis C. She had previously had

a number of jobs, including working in a pinball parlour as well as owning a business selling

flowers to the public.

Participant one describes a long history of intravenous drug use, initially commencing at age

22. During interview, she described being prescribed “Veganin,” an oral medication containing

paracetamol and codeine, and being administered morphine by injection by a home visiting doctor

for menstrual pain. Her initial experimentation with heroin “clicked,” and she described it as giving

her a feeling of relief similar to these occasions. Participant one advised on assessment that she

often used heroin to cope with social anxiety. Participant one began on the methadone program at

age 42, ceasing when incarcerated for fraud at age 68; this was a high-profile fraud case covered by

the media, resulting in the “outing” of her heroin use to her eldest daughter’s in-laws and friends.

She also had periods of abstinence due to court-mandated detox and rehabilitation stays, and after

being gaoled, quickly resumed heavy heroin use and resumed methadone to control this use. She

currently takes 15mg daily, picked up at her local pharmacy, and openly admits to using $100 of

heroin on pension day. Participant one also smokes tobacco (cigarettes).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 160

Participant one’s general practitioner described a 40-year history of depression, and had

commenced an antidepressant, paroxetine, which participant one was poorly adherent to. She

reported a long-term goal of ceasing both heroin and methadone, in order to play a more active role

in her grandchildren’s lives. Participant one lived in a three-bedroom, double storey house alone,

with a moderate level of hoarded belongings, and openly admitted that she had not been upstairs in

years. She also presented with poor eye contact, hypersomnia, anhedonia, poor motivation and

general malaise.

Participant two.

Participant two was a 64-year-old divorced male, living alone in government housing. He is

financially supported by the disability support pension. He has a medical history of COAD,

hepatitis C and a possible acquired brain injury stemming from a motor vehicle accident in 1997.

Participant two has an adult daughter from his marriage who he has no contact with presently. He

has not worked since 1977, and prior to this worked as a mechanic.

Participant two has a long history of case management by public mental health services,

predominantly involuntarily under the Mental Health Act. He has a diagnosis of paranoid

schizophrenia, initially diagnosed in the late 1970s, and presently managed on a fortnightly

zuclopenthixol depot. Participant two continues to have regular admissions to public health

services, often with police assistance, and his relapse manifests as antisocial behaviour,

occasionally with violence. He has also had a number of serious suicide attempts. Participant two

also tends to collect belongings that have been abandoned for rubbish collection, and on assessment

by MAPS, was living in squalor. His premises required an industrial clean by a specialist contractor

who also removed six cubic metres of hard rubbish. Due to his antisocial nature, participant two

alienates community services, who refuse to provide care in his home. He also frequents a local
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 161

Hare Krishna temple and restaurant to volunteer, however is occasionally banned from this venue

due to threats of violence.

Participant two currently uses approximately two grams of cannabis daily, with a history of

intravenous amphetamine and heroin use. He often forgoes food and paying utility bills to purchase

cannabis. Previous attempts to cease use or cut down have been unsuccessful, although he does

describe receiving acupuncture many years ago leading to a six-month period of abstinence.

Participant two also smokes tobacco (cigarettes).

Participant three.

Participant three was a 68-year-old male residing in a supported accommodation service. He

is financially supported by a Veteran’s Affairs pension. His medical conditions include hepatitis C

and diabetes. Participant three has a daughter from a past relationship who he maintains contact

with. He has a diagnosis of schizoaffective disorder, initially diagnosed in 1968 and resulting in

many lengthy hospitalisations in the public mental health system.

Participant three served in the Army, however was discharged due to criminal actions

believed to be associated with his psychosis. He commenced smoking cannabis while an inpatient

in a large psychiatric institution and has used a variety of stimulants and hallucinogenic substances

since. He currently describes frequently using cannabis and alcohol, and infrequent use of

psilocybin (magic mushrooms) that he forages for in local areas. Participant three also uses tobacco.

He was commenced on clozapine in 2008 due to treatment resistant symptoms complicated by drug

use, which have included psychotic episodes that have resulted in police apprehension.

Presently, participant three has been well psychiatrically since 2008 (his last

hospitalisation). He remains disorganised at times, however attends for monthly clozapine reviews
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 162

at the clinic. He is isolative and spends much of his time sitting alone in parks when away from the

supported accommodation service. At the time of the research project, he was enjoying increased

contact with his daughter.

Participant four.

Participant four was a 74-year-old male living alone in an office of housing one bedroom

flat. He has a long history of paranoid schizophrenia, with an index admission in 1974, and many

admissions to public mental health services and treatment as an involuntary community patient with

depot antipsychotic medication. He migrated to Australia in the late 1950s and has held a number of

primarily manual labouring jobs. He has also spent a period of time homeless, living on the street

and in rooming houses.

Participant four mainly experiences positive symptoms, including persecutory delusions

about government agencies and paranoia about neighbours stealing from him and the presence of

germs in his ears. He has a long history of non-adherence to medications, with poor insight into the

need for antipsychotic therapy, and has been trialled on a number of typical and atypical

antipsychotics and a mood stabiliser. He currently takes oral olanzapine and his case manager

reports good adherence. Participant four currently consumes alcohol, the amount of which is

difficult to quantify. He freely admits to heating wine in a saucepan, consuming around a bottle in

an evening, however is elusive when asked as to how often he does this, reporting it as being only

for “special occasions.” However, his medical record demonstrates documented evidence of higher

consumption, such as a large stock of alcohol present in his flat. His oral intake is poor, as he

believes that wine is all he needs to consume to sustain himself. As a result, participant four has lost

a significant amount of weight while under the care of MAPS.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 163

There are concerns around the ability of participant four to remain in independent

accommodation, as he relies on his sister to provide meals and assist him with cleaning. He has

become socially isolated due to irritable bowel syndrome, with participant four concerned about

diarrhoea and subsequent faecal soiling in public. He also has macular degeneration, with psychotic

beliefs about injections preventing treatment to prevent his loss of eyesight.

Participant five.

Participant five was a 64-year-old male residing in a private rental property with his partner

and her seven-year-old daughter. He has a long history of polysubstance use and was diagnosed

with bipolar affective disorder in 2004 after an episode of elevated, agitated and aggressive

behaviour. He has poor adherence to his prescribed medications. He has also attended an inpatient

rehabilitation service for drug and alcohol dependence. Participant five has numerous criminal

convictions. He came to the attention of MAPS after a manic relapse, which resulted in police and

ambulance attending his home and conveying him for an inpatient admission involuntarily. He has a

number of medical conditions, including liver cirrhosis and chronic obstructive airways disease.

Participant five describes a long history of drug use, commencing with cannabis and heroin,

and leading to methamphetamine use. He was involved in a serious car accident, and after this event

began injecting crushed opiate pain medications. Participant four also drinks alcohol heavily with a

peak consumption of 24 cans of beer daily. He also smokes cigarettes. Participant four currently

describes a period of abstinence from illicit substances and prescribed or illicitly obtained opiates,

and at the insistence of his partner, now only binge drinks weekly to fortnightly. During these

sessions, he consumes a substantial amount of “mixer” cans of bourbon and cola.

During the writing of this thesis, participant five was admitted to hospital with dyspnoea,

falls and confusion. During this admission, his condition deteriorated, and palliative measures were
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 164

instituted. He died in hospital, with the cause of death being “aspiration pneumonia secondary to

haematemesis secondary to liver cirrhosis secondary to chronic hepatitis, complicated by COPD,”

[death certificate entry].

Participant six.

Participant six was a 72-year-old divorced male, living in a private rental flat, financially

supported by the aged pension. He was referred by his GP due to increasing anxiety over a six-

month period, the precipitant stressor being legal proceedings around contesting his father’s will.

Participant six has had two prior public mental health service admissions, one in the 1990s for

depression, and the second in 2009 due to lowered mood after ceasing alcohol. He has a long

history of alcohol consumption, peaking at 40 standard drinks per day. After attaining abstinence

two years ago, participant six has recently recommenced consumption of “a tumbler of brandy” to

aid sleep.

Participant six’s medical history includes bilateral knee replacement, impaired glucose

tolerance and hypertension. He has four children who he has intermittent contact with and is largely

isolative in his flat apart from social activities with a friend. On assessment for admission to MAPS,

he described anxiety as preventing him from undertaking tasks such as catching a local bus. His

anxiety and depressive symptoms have also manifested as insomnia, and despite a prescription to

temazepam, participant six described his use of alcohol as helping to attain and maintain sleep. His

antidepressant therapy is venlafaxine 150mg, prescribed by his general practitioner.

Despite scores of 30/30 on mini mental state examination (MMSE) and 30/30 on the

Montreal Cognitive Assessment (MoCA), both considered “gold standard” measures of dementia

(Nasreddine et al., 2005; T. Smith, Gildeh, & Holmes, 2007), a psychiatrist’s assessment of

participant six discerned moderate executive dysfunction which was felt to be of a vascular nature.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 165

As a result, participant six described a number of anxieties around keeping appointments and his

ability to perform day to day tasks, which were felt to be in keeping with this level of cognitive

decline.

Content Analysis

Content analysis of data garnered from the interviews was a considerable task, involving

hand transcription by the researcher as requested by the ethics committee. This determination was a

condition of ethics approval and was requested to ensure privacy of the data obtained during the

interview process. In spite of the level of work involved transcribing the interviews for both of the

qualitative phases of the project, it did allow a chance for the researcher to revisit the interview,

intricately reviewing responses to the semi-structured questions provided. After transcription,

completed transcripts were loaded into the NVivo for Mac software program. This process allowed

more comprehensive coding than traditional “pen and paper” coding, and also ensured greater data

security with the provision of data encryption and password protection (Johnson, Dunlap, & Benoit,

2010).

Content analysis discerned four core themes, including the notion of addiction as a career,

patterns of drug use, complexity, and the drug and the mental illness. A number of sub-themes

emerged from the core themes, capturing each individual’s experience of both mental illness and

AOD use disorders, as well as interactions with mental health services over time. These themes are

explored in greater detail throughout this chapter.

The notion of addiction as career.

As discussed in Chapter Three of this thesis, several scholars in the addiction research field

have likened addiction to a career. This definition has been drawn from apparent similarities
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 166

between “law abiding” occupations and the process of drug addiction, particularly around the

amount of time invested in sourcing and consuming drugs and alcohol (Faupel, 1991). Additionally,

use is noted to move through a pattern of experimentation, addiction and the substance often

becoming the primary activity for an individual (Best et al., 2008). Adler and Adler’s (1983)

seminal study extends this idea to drug traffickers and dealers and noted a similar pattern,

mimicking a traditional career: early stage “hard work” to establish oneself in the field, a rise

through the ranks and eventual disenchantment and/or law enforcement attention leading to

cessation of drug dealing activities.

The Australian Injecting and Illicit Drug Users League (AIVL) describes drug use careers as

fluid, with users having periods of abstinence, lapse and relapse, and often moving between

substances both in isolation and polysubstance use (2012). Arguably, the notion of career can also

be applied to mental health. Often, consumers have an initial onset of mental illness, followed by

intense hospitalisation and community case management, medication regimes and potential

involuntary treatment under the Mental Health Act. A consumer may go through several periods of

remission and crisis, and during the latter phase may feel that the mental health service is their

primary focus in life.

Throughout the interview process, the participants described experiences that fit with the

definition of addiction as a career. In addition, they spoke of mental health services in a similar

way. This section describes the dominant theme of addiction as career, and the sub themes that

emerged during the interview process.

Onset.

Each participant had a divergent entry into both drug use and mental ill health. When using

the analogy of career, the point of onset into drug use followed a similar trajectory to any other
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 167

career, often beginning with innocuous, experimental or social use of alcohol or substances. The

participants all then identified a long period of use, with “fluid” changes to other substances and

varied periods of abstinence described during their interview (Australian Injecting & Illicit Drug

Users League (AIVL), 2012).

As mentioned in the introductory section to this chapter that sought to narrate participant

backgrounds, participant one had an entry into the use of opiates in her early twenties. She

described this as an extension from receiving opiate pain medication previously:

I would say I started using heroin when I was 22. I was in a rehab once and they were talking about when you

first started using drugs. And I was ready for it, you know, 22. But as it got around the circle, all these people

started talking about when they first used strong pills, and other things. And then I thought about our local

doctor, who used to come every month. I had shocking period pains, really bad, had them every time.

And he used to give me injections and I remember the feeling. He’d give me the injection and in 10 minutes

I’d be floating. No pain. Nothing. I could do anything. And that went on until I was about 15 or 16, [until] I

could swallow Veganins, they were old pills that were really strong. And drop 8 or 10 of those and do the trick.

So really, I decided that I got my physical thing for opiates at a far earlier age than I ever thought. It wasn’t

that magically one day when I was 22, I had some smack and it did it. It’s like my body was ready for it or

something (transcript one, page 1).

Accordingly, participant one had a lengthy career of primarily opiate use, although it was

interspersed with brief periods of amphetamine and hallucinogen use. Participant two had

experimented with heroin, also having a lengthy period of amphetamine use leading to psychosis.

Initially, his experimentation with heroin was a result of association with drug using peers.

Proponents of social learning theories of drug initiation and use indicate that peer influence is often

a primary factor in substance use (Oetting & Beauvais, 1987; Oetting & Donnermeyer, 1998; Reyna

& Farley, 2006):

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 168

Using heroin was just… associated with junkies over the years, and I met up with one back when I was a pretty

young kid. He was about 13 when he started. And I lived with him and then I started using (transcript two,

page 8).

Don’t like speed. I used to like speed when I was younger, but I don’t like it anymore (transcript two, page 13).

Despite use of these substances prior, participant two described only using marijuana,

smoked through a bong, daily at present:

I’ve been stoned every day since I’ve lived here. I’ve always had pot (transcript two, page 5).

Participant three had an early onset of mental ill health, resulting in hospitalisation and

treatment in his late teens. His commencement of substance use followed, with him describing

initiation while an inpatient of a psychiatric facility:

I don’t know really. My cousin turned me on. When I was in this [psychiatric] hospital… he visited me a few

times and one day out on the end of the pier he rolled a little joint and said “here, take this,” and he said

“remember, you’re in control of the drug, the drug is not in control of you.” And he said [inhales deeply], and

release… and oh no, it hit me (transcript three, page 2).

Participant three described what “hit him” as being an exacerbation of his psychosis,

including visual hallucinations and paranoia. In spite of this experience, he continues to use

marijuana at the time of writing. His initiation into hallucinogens was also conducted within a

psychiatric facility:

When I was at Morisset [psychiatric hospital] this bloke mentioned it to me, magic mushrooms. I became sort

of interested, or would intrigued be the word? (Transcript three, page 12).

Participant four described early social use of alcohol, particularly in work settings and in the

context of binge drinking. However, when recounting his current drinking pattern, participant three
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 169

identified the presence of side effects from his antipsychotic medications as a catalyst for

commencing problematic drinking patterns. According to the clinical notes present in the

participant’s file, these side effects had been a source of friction between himself and the treating

team throughout his treatment episode:

I started doing alcohol… to put me to sleep. I couldn’t sleep from the injections, the pills and that sort of thing.

I started drinking as soon as I got bored. I bought a bottle of whisky once, a cheap bottle of whiskey to put me

to sleep… then I fell asleep and that was alright. That was a long time ago, that was about… twenty years or

something. I started drinking to wash down the poisons they injected in me (transcript four, page 6).

Participant five used a range of substances, primarily methamphetamine at a younger age,

however began crushing and injecting morphine tablets after a serious car accident. He also used

cannabis frequently throughout his life. Participant five began use of alcohol at an early age,

surpassing all other substance use, and also described the commencement of various substances in

line with life events:

Interviewer: How long ago did you have the accident?

Participant five: Ah, about… 15 years ago now.

Interviewer: And you were prescribed morphine tablets?

Participant five: Yeah. But I would crush them up and shoot them up, (transcript five, page 1).

Interviewer: How was your alcohol use prior to the morphine?

Participant five: Quite extraordinary [laughs].

Interviewer: Can you define extraordinary for me?

Participant five: Yeah, about a slab a day [24 cans of beer].

Interviewer: Okay. When did you start drinking, what age?

Participant five: Oh, about 13, (transcript five, page 2).

Interviewer: What about the ice? When did that start?

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 170

Participant five: That was in Queensland. That was after the accident, I started shooting ice and that

to get over the loss of my loved one up there (transcript five, page 2).

The final participant consumed alcohol initially in social settings, progressing to heavy

consumption over his life. This progression is a common example of problematic drinking in

Australian settings (Australian Institute of Health and Welfare, 2014). Participant five’s dialogue

also indicates that recognition of his as a problematic level of alcohol consumption did not occur

until his drinking was well entrenched, and attempts to cease resulted in mental ill health and initial

contact with mental health services:

What age did I start drinking? Uh, I must’ve been 17 or 18…. Yeah, it was a social thing. Over the years I had

a lot of beers as such, growing up. Yes, had a lot to do with beer over the years growing up. Parties, football

matches. … But it was in the later years that I really thought of controlling it. And then I thought of getting rid

of it, and that’s when I ended up falling on my head. It wasn’t such an easy thing to get rid of it. Because I

mean, as it turned out I went in depression and… I was treated for depression (transcript six, page 8).

The above examples indicate the diverse entry to alcohol and other drug use reported by the

participants in this study. They also highlight the onset of alcohol and other drug use as a career,

which will be explored further in the next section.

The need to use overriding all else.

By definition, a traditional career often becomes a significant part of an individual’s life,

with a substantial amount of time engaged in the activity, as is often the case with income

generating actions such as employment (Hallstone, 2006). Participants in this study described AOD

procuring and using activities as being a substantial burden on their time, and the need to use AOD

as overriding many other commitments. For example, participant one identified her purchasing of

heroin in terms of a career requiring substantive investment of her time and a perceived alienation

from friends, family and associates living non-drug using lives:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 171

Getting the drug impacted. I mean it’s a 20-hour a day job if you haven’t got a bloke who is doing business or

something. You’ve got to have money to use. And everything goes in order to have that money (transcript one,

page 1).

Participant one further elaborated on this point to identify the importance heroin had in her

life, often in conflict with her role as mother to her children:

And that’s another thing heroin does to you I think. There’s nothing I want, no clothes, nothing I… never had

since I was using heavily. Money is heroin to me. Put $200 in my hand and it will be gone in… 20 minutes

(transcript one, page 3).

And I needed a hit in the morning to get myself together and left the kids at home 7:30 in the morning, zoomed

over to [friends] place to get a hit from them… (Transcript one, page 2).

These accounts illustrate the long-held notion of addiction as being a powerful motivator of

ongoing “deviant” behaviour (Klingemann, 1999). In spite of this, participant one proudly indicated

during the interview that her three children had grown into independent, successful adults despite

being raised by a heroin addict, a notion at odds with societal ideas around drug users and an

inability to perform tasks of responsibility (d'Orbán, 1973). Participant two also identified risk-

taking behaviour to enable his drug use, which ultimately resulted in the termination of his

employment:

Interviewer: Did you use speed for long?

Participant two: About 12 months. That was rather funny. When I got found out. When they

found that the dexamphetamine only had one slide in the packets instead of two.

Interviewer: What happened?

Participant two: I got the sack.

Interviewer : Where were you taking it from?

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 172

Participant two: [Pharmaceutical supply company in Australia].

Interviewer: When you were working for them?

Participant two: Yeah, just walk into the section with the dexamphetamine, open up a packet, take

out one slide. 20 pills or whatever, 15 pills or whatever.

Interviewer: Were you a storeman then?

Participant two: Yeah. Storeman, delivery guy… When they sacked me, I was fucking loopy. I went

to a bloody clinic and… all they did was give me vitamin B injections and talk to a

psychiatrist or psychologist or whatever (transcript three, page 14).

The final statement made by participant three also indicates that drug use was common in

spite of the ramifications to mental health. Participant three, who continued to consume substances

in defiance of serious psychotic symptoms, echoed this sentiment:

I started turning into some sort of maniac. I turned into a bloody idiot after a while. Year in, year out, there I

am. Roaring out abuse. And primalling [sic] everywhere I went like a maniac. About 25 years ago when I was

living in South Yarra, and I used to take my football and run through the Botanic Gardens roaring out, like

primalling [sic], you know. I got away with that for about 6 months to a year. Finally, this guy appears from

behind a bush… a gardener… with something that could be used as a weapon, saying, “there are old women

present,” (transcript three, page 8).

Further, participant three described a number of occasions that appeared to be psychotic in

nature, demonstrating the complex interplay between drug use and mental illness:

I was peaking on magic mushrooms… I had a bit of paper with a list of 17 different problems I wanted to

discuss with my psychiatrist written in red. And I went up to the men’s store, I found myself in the men’s

store, and I went into the change cubicle, stripped off [naked] and started walking around.

Anyway, nothing happened then. Then I went down to the women’s store, the store below, I was standing there

near the brassieres and this woman… blushed immediately. Then I sort of did a bit of a pirouette, and the

moment I hit the floor, after the pirouette, there was a big car park right around the store, and then I went back
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 173

to the men’s store and I went to the cubicle and the store detective was there. He would’ve been about 6’3”,

6’4”, a great big solid guy, and he said to me “I’m going to be lenient on you this time, but if I see you in here

again, I’m going to come down on you like a tonne of bricks. I got away with that, got dressed and out of

there… then, uh, on the other two occasions, there I was. I was walking along the street, Collins Street. I did

the city block. Down Collins, right into Swanston, up Bourke then along Exhibition. I got away with it.

Nobody said a word. All I was dressed in was just naked with socks on. And this woman that I know

introduced me to a new person that I hadn’t met before. Another woman, a girl, you know. There was no sort

of, nothing strange seemed to occur.

On the third occasion, it was sort of like an overcast sort of a day. I tried it again and I ran into trouble. At the

corner of Collins Street and Swanston Street, it was one of the boys, one of the policemen. He goes “alright

you, come on,” and he gives me his policeman’s hat and goes “put that over it.” And I went like that then he

said “you’re not going to piss in that are you? Put this over it,” then he gives me his notebook. Then they took

me to the station. Looking back on it… did that happen? Did that occur? (Transcript three, page 14-15).

In addition, use of AOD had often led to legal complications. Participants described

understanding that legal ramifications were a possibility of their actions, however continued the

behaviour in spite of the consequences. This sometimes led to a misunderstanding, as everyday

activities were often completed under the influence of AOD due to the large impact it had on the

participant's everyday lives, as indicated by an account from participant six of being apprehended

for impaired driving:

I got pulled over once for drink driving… It was a random breath test. What had happened was I was drinking

with my family on the Sunday, and this friend of mine who'd been in an accident she came down on crutches.

And I felt sorry for her, and I thought I'll give you a lift home. So got in the car, got her in the car, got safely

up the road, and then a police car pulled me over. I said, "what's wrong officer?" And he said "It's just a

random check. Could you breathe in to this?" That's how he got me. Just a random check it was. And I thought

to myself doing my friend a favour, running her home, which was only five minutes up the road… I thought

that was terribly unlucky. I even told the policeman, "Was I driving erratically or something?” And he said

"no, no, you're right." So that's how I got picked up (transcript five, page 4).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 174

Of note is the participant's potential to normalise this behaviour, in explaining that his

driving wasn't impaired in spite of exceeding the limit. Using AOD also had a financial cost for the

participants, with many forgoing essential items to continue to afford ongoing use. This generally

may have not been a lifelong pattern, however at the time of the interview some participants

described financial difficulties. This was also evidenced by the number living in Government

housing or funded residential services (four). An example of the fiscal pressures of use are

illustrated in this example from participant two:

8 years. 8 years I've been stoned every day. Well not every day, there's been a couple of days in between,

but… Oh, $40 [of cannabis] a day I guess… (Transcript two, page 5).

Participant two then described going without groceries and utilities to ensure he had his $40

to spend on cannabis daily. At the time of interview, participant two was living in a squalid Office

of Housing Flat. He had significant debts to utility companies, and had his electricity, water and gas

disconnected a number of times, although he managed to reconnect it himself due to his mechanical

background. Participant two relied on food hand-outs from local charities to eat.

This section indicates that the use of AOD often overtakes all other priorities that society,

and clinicians, may judge as being more important for an individual. For example, the use of AOD

by these participants has resulted in financial and legal costs, a toll to their mental health and

isolation from family and friends. They described being reliant on external services to manage the

later stages of their lives. In spite of the media sometimes reporting addiction as being a "choice"

made by users, these accounts do not illustrate a logical decision-making process, rather one driven

by the primary need of maintaining an addiction (Kalivas & Volkow, 2005). As discussed in

Chapter Eight, this finding has serious implications for a clinical position advocating abstinence as

a pathway to better mental health and societal functioning.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 175

Changing drug worlds.

Throughout the interview process, participants who used illicit substances spoke of a change

in drug worlds. This finding is in accordance with Levy and Anderson's (2005) work with injecting

drug users that was discussed in Chapter Three of this thesis. In fact, the participants who used

predominantly alcohol also spoke of a different nature of drug world, where the consumption of

alcohol had been largely a social event in public, however the bulk of their consumption was done

in private; this led to a discordant public identity of the stereotypical social drinker in public and a

dependent alcoholic in private. Participant six demonstrates this point through his account of his

former working life and the expectations of binge drinking that accompanied it:

Once I was a storeman… The firm took us to the pub, and uh…. Free beer. I drunk 24 glasses [laughs]. I had

no food, nothing, worked hard and the work was easy. But no food makes it a problem, because not enough

energy to do every job. I came back on the train and stopped before the junction, I collapsed drunk (transcript

six, page 7).

As mentioned in the onset section of this chapter, participant six commenced heavy drinking

to counteract side effects of psychotropic medication. He reported doing this because "It was

logical. If you’re drunk, you fall asleep, and that’s all. That’s logic, my logic. That’s why I bought

alcohol to make myself fall asleep," (transcript six, page 8). Arguably, being socialised into a

drinking culture that encouraged intoxication shaped participant six's current drinking habits.

Participants involved in illicit drug use spoke openly of changes in drug worlds associated

with these substances, with participant one describing polysubstance use as being common in the

present day, which was at odds with her experience of using only one substance at a time:

See that's how it's all changed in the different generations. I don't know anyone who would do what some of

those young ones do. Who would want to eat a packet of antidepressants, you know, with a hit of speed? I

mean, it just doesn't enter my head, whereas the young ones will do anything (transcript one, page 14).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 176

This was reinforced by participant five, who found himself immersed in illicit drug worlds

while obtaining licit medications; in this case, purchasing morphine sulphate tablets on the ‘black

market’ to supplement those which were prescribed through legitimate means:

Yeah, when I had to, the necessity. I also sold it on the black market, which… Only when I was asked by other

druggies do I have anything spare. You seem to be in another culture, when you're in with that (transcript five,

page 8).

Participants also spoke of a perceived change in purity of substances resulting in their

reluctance to use substances, however in the case of participant one, this led to her believing that

contemporary heroin was so impure it was impossible to overdose on. Despite this belief, during her

MAPS care episode she was found by clinicians having overdosed twice. She also hints on this

perceived reduction in purity as a reason for individuals having to use many substances together:

Smack has changed again in the last year or two even. Because the money's in ice and speed. And see, when

heroin was worth using, like when it was, because the heroin that's on the streets now is terrible, it was better.

Because people that used heroin used heroin. They didn't want to go out and use anything else to spoil the

smack (transcript one, page 14).

Conversely, participant two identified adulteration as a reason for him to avoid the use of

contemporary heroin, despite a short history of prior usage:

Oh, about 6 months [heroin use]. Occasionally. Now I don't do it at all. Don't trust it. Never know what you're

getting (transcript two, page 4).

Participant two also identified, through his extended time period of cannabis use, the

movement of dealers in and out of the drug world. This echoes the conclusions of Adler and Adler's

(1983) seminal study of drug distribution, where the authors identified various career trajectories of

drug dealers, including cessation due to the perception that legal ramifications were close:
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 177

I've lost, I used to have about 8 dealers and I've lost 5 of them. They've moved. It's got too hot where they're

living so they've moved somewhere else (transcript two, page 17).

Accordingly, participant two identified that buying cannabis had been solely based on

availability. He tended to enmesh his social networks with his chosen drug dealer and the other

users who purchased there. This indicates one of the challenges with attempting to abstain from

substances: users are often immersed in social networks that are heavily invested in drug use,

therefore removing oneself from these networks would result in social isolation. An interesting

observation on availability is that of the availability of alcohol, with research indicating that alcohol

is cheap, readily available and socially acceptable to purchase (Brand, Saisana, Rynn, Pennoni, &

Lowenfels, 2007; Livingston, 2012). Participant four summarised this during the interview, where

he spoke of alcohol as being plentiful and cheap in a shop nearby:

All over the place, bottles are cheap, $5.50. I buy from a bottle shop just up the road. It’s good quality, it’s

good in winter, (transcript four, page 10).

Changing drug worlds would seem to have an impact on the substances consumed and

patterns of consumption in the participants of this study. This is explored further in the next section

of this chapter.

"We are dying of things normal people die of."

An interesting finding of this research process was the notion of older adults with dual

diagnosis describing themselves as dying of "normal" events that a non-dually diagnosed individual

would suffer from, as well as expressing surprise at getting to old age in spite of heavy use of AOD.

For example, participant one described her network of friends, mostly heroin users themselves,

dying of overdose at early ages. However, when speaking of her current using peers who remained

alive at the time of interview, she stated:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 178

I don't know, people die. Like, all my friends who've died in the last ten years, none of them have overdosed.

They've just died of… cancer and heart attacks (transcript one, page 4).

Despite living older ages, the participants in this study still experienced a multitude of health

problems, often related to their use. This is explored further in the 'Complexity' section of this

chapter, however the following example indicates this notion:

Interviewer: This is what I hear a bit, people go “I can't believe what I've done through my life,

and I can't believe I'm still around,” basically. Is that something you… can relate

to?

Participant five: Yeah, 100%. Who'd think I'd get to 65? [Laughs].

Participant five's partner: Even his carer said, he was carrying on the way he was last year, right until

December, and the carer said he's only got 3-6 months. And I used to go "really?"

And, uh, and I just think what a shame, couldn't he turn it around, or if he… had

something worthwhile in his life. Because he is such a caring, gentle person that

you'd think… yeah, you know, can something help. Because everyone allowed him

to drink and smoke, they were getting him his alcohol and everything. So I just

think he was sitting there like the king and going "yeah, here's some money, get me

another slab [24 cans of beer]," every day, and have my carton of cigarettes. You

know, more than a carton a week, and people were just watching him and just

turning a blind eye, Even with the dope smoking, I couldn't believe it, he had

representatives coming out and allowing him to just smoke it everywhere (transcript

five, page 15).

As described earlier in this chapter, participant five died after the interview process was

conducted, indicating the substantial medical comorbidities he had in addition to his AOD use and

mental ill health. When exploring this issue with participant five, he responded in a manner that

seemed to minimise his serious health concerns at the time:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 179

Interviewer: At 65, you've gone through this life where you didn't think you were going to get

here, because you've lived this pretty hard lifestyle. How do you feel now that

you've got to this age?

Participant five: Unbelievable [laughs].

Interviewer: In a good way or a bad way?

Participant five: In a good way I suppose.

Interviewer: Good. It sounds like you've got a few health things going on?

Participant five: Yeah, nothing I can't overcome, (transcript five, page 18).

Participant three echoed this when describing his use of hallucinogenic drugs previously,

punctuating the discussion with this statement:

I don't know really, um, looking back on it like why am I still here, I should be dead. You know what I mean?

Ever had that feeling? (Transcript three, page 12).

The idea that arriving at old age, after a long period of alcohol or substance use may

reinforce the notion that AOD use is not particularly harmful. This is often expressed by consumers

and healthcare professionals alike as people "needing to die of something," and contributes to the

inertia in making changes despite obvious effects on physical and mental health (Dar, 2006).

Extended lifespans may also be the result of the success of harm reduction initiatives,

primarily needle exchange programs that have been proven to reduce the rate of mortality from

blood borne viruses (Ritter & Cameron, 2006). Two of the participants described injecting

behaviours that were previously risky, with participant three disclosing an account of having a

friend inject him with unknown substances which he believed to be a combination of amphetamine

and cocaine:

Interviewer: Do you use that IV [intravenously]? Inject?

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 180

Participant three: A friend of mine injected me.

Interviewer: You must have a lot of trust in your friend to be injecting you.

Participant three: Yeah, (transcript three, page 4).

Participant one spoke of the changing drug scene in the 1980s, where a transition from

sharing injecting equipment to obtaining clean needles and syringes for use became commonplace

due to fears of blood borne virus mortality:

Well anyone with a brain stopped sharing fits in the mid 80s, as soon as we found out about AIDS. We were

absolute pigs before that, I can tell you. We used to have a table of fits with blood in them, didn’t matter, once

the dope hit you just grabbed one, pulled some water up and used it. But once the AIDS thing hit, and you

know, the news got through to us that finished. And… When the needle places opened and you could go and

get a box. So, we’d go down and get 10 boxes [laughs], and the lady at the counter would say, “Oh do you

need that much dear?” Yes. And we’d all have enough (transcript one, page 9).

Regardless of the reasons behind extended lifespans in this population, both these findings

and the literature examined in Chapter Three of this thesis provide evidence to challenge the notion

that individuals who use AOD succumb to mortality prior to reaching an age where they can be

described as "older." Discussed further in Chapter Eight, the impact of an ageing population and

extended lifespans of older adults with dual diagnosis may pose a substantial challenge to service

provision to this cohort in the future.

Patterns of drug use.

Patterns of drug use in older adults are a topic that requires examination. During the

interview process, participants described diverse AOD use both throughout their lives and at the

time of interview. As identified in the literature review of this thesis, AOD use is often recognised

as a fluid phenomenon, with periods of abstinence, changes of substance and various treatment

approaches often trialled during a lengthy period of use. The following section explores the current
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 181

use of the participants in the study, the phenomenon of adaptive use, relates the concept of AOD

use as self-medication for ill mental health to the participants in the study and finally discusses the

participant's description of their intent and efforts to make changes to their AOD use.

Adaptive use.

Adaptive use is the changing of alcohol or drug use in accordance with advancing age,

availability or physical tolerance, as discussed in Chapter Three (Levy & Anderson, 2005).

Adaptive use was apparent in the accounts of participant one, a long-term injecting opiate

user, who self-reported her present use as fortnightly when paid her pension. She used a

small dose of methadone (15 milligrams daily) to control her craving for opiates and

maintain her use at a level she felt was appropriate for her age:

So that, in the morning I don't wake up with that feeling I want to get on. And that's probably ridiculous, you

know. I went off it 3 or 4 years ago, but then I started using again and needed to go back on it. Just because,

when you're using, when you wake up the first thing on your mind is getting on. And it's horrible (transcript

one, page 14).

All of the participants in this section of the study described some form of adaptive use as

they grew older. This may have been a result of medical comorbidities, or financial or social

pressures. Participant five, who described a long history of polysubstance use combined with

alcohol abuse, had adapted his use under the tutelage of his partner:

Yeah, I binge drink but… might be a fortnight in between drinks and that. Between six and eight cans [in a

drinking session] (transcript five, page 3).

When asked why participant five felt the need to stop, he cited external influences as the

driver of his transition from daily drinking to binge drinking:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 182

Well, [participant's partner told me to quit smoking] And I’ve agreed with [participant's partner]. I said I might

have a drink, but that is my right, you know I haven’t got any bans on drinking. But I don’t drink every day or

anything like that (transcript five, page 10).

As a result, participant five believed his current, adapted use to be less harmful than

previous levels of use, in spite of it being beyond current guidelines for alcohol consumption in a

single session (National Health and Medical Research Council, 2009). His partner also described a

reduction in medical symptoms she attributed directly to alcohol. This was echoed by the

description of participant six, who also explained his reduction from a substantial pattern of

drinking up to twelve cans of beer daily to a tumbler of brandy every night to aid sleep. He then

described using temazepam for a period of time while abstinent, and then reverting to alcohol to aid

sleep when he felt a tolerance to benzodiazepines had developed. This seemed to be reverting to a

long-established pattern of behaviour for participant five, who historically described his heavy

drinking as necessary to attain sleep:

No, no. Well, what it did do for me [drinking]… Helped me go to sleep and sleep. And to compensate for that

in recent times I've uh, got from the doctor temazepam. But what I've found after having that for so long is that

you become immune to it, it doesn't knock you out like it should. [You] build up tolerance to it. In which case

is why I find in the evening now I've got to have a shot of brandy. I do that mainly because it helps me go to

sleep, where the temazepam did, and helps me stay asleep. And have a restful night's sleep… Whether it's

psychological, or it's the alcohol content itself is… what helps me go to sleep rather than temazepam. I used to

like the temazepam too but without a tolerance to it I could go to sleep very well. But um, now I find these

days I've got to have the brandy (transcript six, page 2).

In spite of the clear risks of such a strategy, for example building a "tolerance" to brandy

and returning to prior levels of heavy alcohol consumption, participant six felt this adaption to his

present style of drinking was not a concern, describing it as medicinal, a curious statement given his

cited reason for abstinence previously was due to health concerns:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 183

Well, because I don’t consider myself to be an alcoholic, as such. Okay, it might sound, …a drink every night,

but it’s only a tumbler half full of the brandy and go to bed and then… it works. So it’s only for medicinal

purposes as I see it, not drifting back in to a world of crazy drinking (transcript six, page 2).

Participant three also described an adaptive pattern of use in line with health concerns,

identifying the respiratory symptoms experienced from heavy cannabis smoking:

I suppose the main thing is that all it really results in is a harsh cough. Smoker's cough. And of course, you

know that one that you can smoke yourself straight (transcript three, page 7).

Participant three also raised concerns with tolerance to cannabis: "you can smoke yourself

straight." Conversely, participant four expressed that his alcohol use was primarily to counteract

side effects of antipsychotic medications, as explored earlier in the onset section of this chapter. His

true level of alcohol consumption was difficult to ascertain and had been a concern for his MAPS

case manager for some time; participant four had described ongoing drinking for "celebrations,"

however these sometimes became daily events with dubious reasoning. During these periods, he

consumed primarily wine that he cooked in a saucepan, however had adapted his use previously

when placed on an injectable depot antipsychotic medication:

It was logical. If you're drunk, you fall asleep, and that's all. That's logic, my logic. That's why I bought alcohol

to make myself fall asleep… So what, drinking at home, you collapse in bed and sleep. That's my logic, that's

why I drink (transcript three, page 8).

The concept of adaptive use in older adults who use AOD is one that warrants further

investigation. This is particularly evident when exploring benzodiazepine dependency, as touched

on in the discussion with participant six who described a pattern of moving from temazepam to

alcohol and back when he felt the tolerance destroyed his capability to sleep. Benzodiazepine

dependence is a significant issue in older populations and is often overlooked or not disclosed due

to the fact that there is a pervasive attitude that medications prescribed are not problematic (Closser,

1991; Simon & Ludman, 2006).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 184

Adaptive use makes AOD more difficult to detect in older adults, particularly as individuals

move from cohort to cohort, for example from being maintained on a methadone maintenance

program to using cannabis and benzodiazpeines obtained from many different prescribers. It may

result in individuals presenting to a number of potential providers of care, making cohesive

treatment difficult to attain (Wilsey et al., 2010). Adaptive use will be discussed further in Chapter

Eight, however the key observation is that adaption of AOD use is a substantive barrier to service

provision in older adults with dual diagnosis.

Contemplating changes to use.

As mentioned throughout this analysis, AOD use had a number of costs for each participant

in this phase of the study. Accordingly, five of the participants made statements indicating their

desire to cease or reduce their use of substances. This finding challenges attitudes that older adults

should be either allowed to continue their use unabated as enquiring about AOD use is seen to be

taking away one “last vice,” or that older adults who use AOD are “set in their ways” and therefore

AOD treatment would be a futile endeavour (Allsop & Stevens, 2009).

Participant one mentioned the financial cost of using AOD as a negative aspect to sustained

heroin use. The example below indicates the long term fiscal cost to participant one's family of her

heroin use, resulting in a reliance on services provided at a State and local council level to remain

housed. When asked to comment on the financial effects of heroin she stated:

Oh massive. Ask my daughters. No, we always got through. I mean, when you’re on your own it’s easy. Like

when you’ve got kids, but I was blessed with places like the [local council]. They rented us a cheap house.

And once we had a roof over our head, food and everything was easier. But, they didn’t have ice cream in the

fridge, or… now that they’re grown up they’re glad, let’s put it that way that they weren’t bought up on shit.

You know, the kids down the road would have all these bloody awful plastic toys, zooming things, and my

girls thought they wanted them, but they realised they didn’t. When they got older (transcript one, page 4).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 185

In spite of the realisation of the financial cost heroin had taken on her life, participant one

described her current desire to achieve abstinence as being based on attaining a sense of control

over her opiate addiction:

I didn’t go on [methadone] until I was about 45. We held out against it, you know, because before that French

junkies used to be on methadone. And, we used to look at them and feel sorry for them. Oh dear, but then it got

to the point that I had to go on it (transcript one, page 15).

Accordingly, participant one expressed a long-term goal to her case manager of ceasing her

fortnightly heroin use and eventually discontinuing her methadone maintenance treatment.

Participant two was more ambiguous regarding his reasons to change, citing a general desire to

change his lifestyle as a reason for ceasing cannabis use, however his initial dialogue did focus on

running out of cannabis prior to being paid his fortnightly pension and the stresses associated. He

went on to describe feeling frustrated with this lifestyle, expressing a desire to cease his use:

I wish I didn't do it [smoke cannabis daily]. Trying to [quit], but not succeeding, I'm sick of doing it (transcript

two, page 5).

In itself, this finding is significant when considered alongside the history of participant two,

who had frequently been treated as an individual with heavily entrenched substance use patterns,

which had resulted in his motivation to change not being explored during the majority of his mental

health service involvement. Medical issues were also cited as being a reason for change, as

indicated by participant six:

Well I virtually said it can't be good for my body. That's what I said to myself. It can't be good for my body…

because my grandfather died of cirrhosis of the liver, and I thought of him. I thought give it away, beside it

being sort of expensive. When you stop and think about it in retrospect it was an expensive way to go to sleep

(transcript six, page 4).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 186

Prior to his involvement with the mental health service, participant six had suffered a stroke.

In spite of his return to controlled drinking as discussed earlier in this chapter, participant six did

not equate this as a health problem resulting from prior drinking. When asked about health issues as

a result of drinking he replied:

The only health issues I’ve basically had are replacement knees for arthritis, and the recent bout of having a bit

of a stroke. Mind you, um, I think I had a warning before that stroke. A warning in as much as this eye, I went

blind in this eye for a number of weeks. That was a minor stroke (transcript six, page 6).

The above passage illustrates the opposite of expressing a desire to change and has been

termed "sustain talk" by leading proponents of motivational interviewing, a counselling

methodology specifically designed to determine and elicit change in behaviours (Miller & Rose,

2009). In itself, sustain talk is an expressed resistance to change, and often expressed as

minimisation of the extent of AOD use as illustrated by participant four:

Yeah [drinking is] good for health. In my youth, I’d go to a restaurant… I got as drunk in my youth but that

proves I’m only drinking for celebrations (transcript four, page 10).

In spite of a reported minimal use of alcohol, participant four suffered from several health

problems and as discussed in the participant background section of this chapter, his actual

consumption of alcohol appeared to be incongruent with his reported amounts. Another example of

attempts to justify ongoing use was evident while interviewing participant six, who spent a

significant amount of the interview explaining how his present consumption of alcohol was

markedly different from past levels and patterns. During the interview, he was asked whether he

still related to the term alcoholic and considered himself as having an alcohol problem despite his

apparent reduction in consumption:

No, I don’t. I don’t, because it’s the same way you would have temazepam as a medicinal answer to it, I find

the brandy is medicinal to me. So, what’s basically the difference? If I have half a tumbler of brandy to go to

sleep, it’s the same as if I have a sleeping tablet. See, tonight, okay, I say I'm not an alcoholic, but I'll look
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 187

forward to when I want to go to sleep, and drink the brandy, have the brandy, turn off the TV and uh… just lay

my head back on the pillow (transcript six, pages 4-5).

These findings reinforce the importance of ongoing assessment of an individual's readiness

to make changes to their AOD use rather than viewing consumption of drugs and alcohol as an

entrenched problem. They also highlight the importance of psychotherapeutic skills in the

professional relationship between clinician and consumer, which will be discussed further in

Chapter Eight.

The concept of self-medication.

Self-medication, described in the literature as a tendency to use AOD to reduce emotional

distress is frequently cited as a common reason for substance use comorbidity in individuals with

severe mental illness (Bolton, Robinson, & Sareen, 2009). Studies of self-medication often cite

individual reasons for use as a relief of psychiatric symptoms and improving social abilities

(Bizzarri et al., 2009). During the interview process, the participants indicated a degree of self-

medication of their mental health symptoms, citing the use of AOD as necessary to maintain

everyday functioning in light of persistent mental ill health. Participant one, who described a

protracted period of depression with anxiety, described heroin use as a relief of her depressed

mood:

It just feels fantastic for the time you've got it. And you'll do all that, forsake all that for a few hours of just…

that wonderful feeling (transcript one, page 3).

Participant one also described periods where her mood had deteriorated, often preventing

her from leaving her residence and engaging in social interactions with friends and family. During

these periods, she did not seek professional help, instead describing the use of heroin to lift her

mood. As the following example indicates, this was often in the context of significant social
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 188

stressors occurring in her life, although this example also indicates that respite from these situations

was also beneficial:

I've had various times when I've needed some help, but mostly I've self-medicated [laughs]. I did have a period

where, in a violent sort of relationship, ended up in a hospital… And after about two weeks sort of came out of

it. I sort of turned off for a couple of weeks. Like I was there but not there (transcript one, page 5).

When directly queried as to her tendency to seek heroin to ameliorate the symptoms of

depression, participant one described it as a drug with euphoric effects that she felt improved her

mental state, comparing it to prescribed substances to treat depression as follows:

I used to say to doctors, you know, don't give me antidepressants, give me some heroin. And they'd say nah,

but I meant it. See, I still don't get it, it's the most amazing drug ever been made by human beings. And they

treat it like it's poison. You know, it's crazy (transcript one, page 7).

Likewise, participant two described his smoking of cannabis as a method to keep his

symptoms of schizophrenia under control; he described that without cannabis, his mood quickly

became depressed and his agitation and aggression intensified. When asked whether he felt daily

cannabis consumption had an effect on his mental health, participant two stated:

Not really. If anything, it's kept me balanced… I can always see the bright side of life (transcript two, page 7).

The notion of using substances to cope with serious mental illness was present throughout

all of the interviews, however participant three identified the relief he gained from using substances

as a hindrance to ceasing use. This relief was what made it difficult to stop use:

I suppose because of the feeling it gave me, you know? Searching for that… Overall feeling of wellbeing as

someone once put it (transcript three, page 9).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 189

The above interaction indicates one of the primary difficulties in attempting to motivate

individuals with dual diagnosis to cease or reduce their AOD use. Accordingly, while individuals

may be able to attain abstinence of a sense of controlled use, this often becomes difficult in the

setting of mania. Participant five described this phenomenon well, explaining that his substance use

and the risks associated with it often increased when his mood elevated:

Interviewer: And when [your mood is] high, have you found in the past that kind of coincides

with an increase in your drug use, or is it more when you get low?

Participant five: No, the high.

Interviewer: Does it tend to go with that conquer the world kind of thing?

Participant five: Yes, it does [laughs] (transcript five, page 7).

As described earlier in this chapter, participant five commenced his methamphetamine use

as a way to manage the emotions related to the death of his then partner: "…I started shooting ice

and that to get over the loss of my loved one," (transcript five, page 2). In itself, this disclosure

indicates the commencement of a pattern of use that meets the definition of self-medication as

described in the opening paragraph of this section. Such patterns can rapidly become an entrenched

scheme of AOD use, which may not become evident until attempts to cease use are made.

Participant six, who described a significant decompensation in his mental state when making the

decision to cease drinking alcohol, illustrated this point; an attempt at abstinence resulted in a

psychiatric admission and exacerbation of his symptoms of depression and anxiety:

When I gave up alcohol, I was… Affected somewhat mentally, mentally. Which I sought help with. I was put

in [psychiatric hospital] for a number of weeks. I… Lost my way with things. I couldn't put two and two

together so to speak. And I thought that, at the time, [psychiatric hospital] could help me. That was

withdrawals after giving up alcohol. Normally I'd been drinking through… Quite a number of years. And their

psychiatry division… Had me out for two weeks. At one stage I could walk to the front gate but I was too

afraid to walk out (transcript six, page 1).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 190

Further on in the interview, participant two described his treatment while an inpatient of the

psychiatric hospital:

They put me on to drugs… To try and help me. A drug that's no longer used anymore called mellaril. Yes, I

had that and I was said to be in deep depression. That's what the analysis was, that I was deeply depressed. I

certainly had to agree with it [the diagnosis of depression], because I saw no other explanation for it. There had

to be a reason why I went basically… stupefied. I needed to be evened out, evened out psychologically. After

giving up the alcohol. I was drinking at least, uh, half a dozen… half a dozen cans or stubbies at night. For

years, this went on for years. I suppose it was relief. Originally, I thought I was… I originally thought that I

wouldn't be able to cope without [alcohol] (transcript six, pages 1-2).

When queried directly as to the reason for his heavy drinking, participant six described it as

a means to attain sleep, which he described later in the interview as being disturbed by ruminating

thoughts of hopelessness and worthlessness. These thoughts had resulted in participant six relapsing

from his abstinence, and resuming his drinking as a means to self-medicate this symptom and attain

sleep:

So that's where I decided to have a half tumbler of brandy, because it was strong enough to knock me out

(transcript six, pages 2-3).

As a concept, self-medication goes some way to explain the motivations for individuals with

dual diagnosis to maintain their AOD use in spite of the emotional, financial and social

ramifications ongoing use may hold for them. Self-medication also highlights the difficulties

inherent in providing AOD treatment to individuals with mental ill health, as symptom control

remains a valid reason to the individual to maintain use.

Complexity.

Evident in the analysis of responses to the semi-structured interview process, the

participants in this study displayed high levels of complexity, generally emanating from three

domains: a high degree of medical comorbidity, the presence of stigma and the need to seek
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 191

treatment from a system not catering specifically to older adults. This section aims to explore these

responses in greater detail.

Medical conditions.

In spite of the idea expressed by some participants that they were dying of things not

associated with AOD use, the use of substances and alcohol had an impact on their lives,

particularly when considering their physical health. The net result of this situation was a

requirement for greater contact with health service providers, and although discussed in Chapter

Three as a potential area for professional stigma, some participants reported mostly positive

relations with clinicians despite their AOD use and mental health concerns. Participant one

disclosed during the interview process that she was always determined to disclose her heroin use to

hospital staff:

But I’ve always been outspoken about it, well, when I say always, for a long time. I just refuse to let doctors

and those people get away with… not recognising people like me and my friends. So I would tell them loud

and clear, I use heroin, so from the outset they know. Still, a lot of my friends are very careful about which

people they tell (transcript one, page 9).

As a result, she felt that the recent quality of care she received had improved from previous

admissions, where she felt that both herself and her friends had been denied adequate pain relief

during her stay. Participant one felt this was a clear consequence of her open disclosure of her

opiate use:

That’s exactly right, we used to not tell them a thing, but if you had tracks [injecting marks] they’d find them.

But to the point of cruelty I reckon. And it would lead to all this unnecessary, you know, some people would

just flip out. Deck [hit] the nurses [laughs]. And they’d deserve it. And, you know, there would be mayhem, all

over a couple of Panadeine Fortes or, or a hit of something to take the pain away (transcript one, page 8).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 192

She followed to discuss a recent admission, where she felt that her opiate use was managed

professionally, in a manner that was sympathetic to both herself and her medical condition at the

time:

I couldn’t believe the Alfred when I went there about eight years ago I went for exactly what I went for this

time, I got this weird pneumonia, and, I was extremely sick. And I just couldn’t believe them, their whole

attitude towards heroin users and stuff. I was unconscious for two or three days, and then, the first day I was

with it the nurse came in with my methadone and I nearly fell out of bed with shock. I said, “What do you

mean my methadone?” She said, “Well here it is.” I mean, I was used to the old days when you’d hang out in

there and they’d treat you like shit. They’d hardly come near you (transcript one, pages 7-8).

Despite this positive account of healthcare interactions, participant two reported poor prior

experiences, particularly with general practitioners. He felt that he was judged as an opiate seeking

patient in spite of legitimate physical pain:

Participant two: Back pain. When I got hit by that fucking car… Crossing the road, and he bowled

me. Like and he saw me, I know he saw me. He just accelerated up that hill like a

crazy bastard like he was trying to kill me.

Interviewer: Have you taken anything for your back since? Any pain killers?

Participant two: Yeah, but I’ve given up on pain killers. They don’t work… It’s not that they don’t

work, it’s getting the bloody prescriptions all the time.

Interviewer: Do you find it hard to get them?

Participant two: Yeah, they fuck you around.

Interviewer: What sort of pills?

Participant two: Oh, just morphine and that. Oxycodones if I can get them.

Interviewer: They’re hard to get?

Participant two: Oxycontin… Oh, I don’t know if they’re hard to get, it’s just hard for me to go and

get them. I just don’t like doctors. So I suffer (transcript two, page 11).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 193

As a result, participant two received very little primary health care in the community,

instead being investigated for physical health concerns during admissions to the psychiatric unit.

Physically, participant two presented as frail, with marked loss of weight and pallor. As previously

mentioned, his oral intake was poor due to poverty, as his funds were often spent on marijuana

rather than food. Participant two acknowledged the effect both cannabis and tobacco smoking had

on his health:

Yeah, yeah it has [affected my health]. I’ve got emphysema, bordering on emphysema (transcript two, page

12).

On interview, participant three presented in a similar fashion, with a pronounced loss of

weight over the last twelve months as corroborated by his case manager. He appeared frail and

gaunt, and again, described very little oral intake apart from alcohol. In spite of this, he felt that his

physical condition had improved over recent months:

Simple cooking. Hot wine with biscuits in the hot wine, that's a meal for me. Couple of biscuits and hot wine

and that's a meal (transcript five, page 4).

I was starved, I was… I wasn’t healthy. And now I’m the healthiest I’ve been and yet I have problems on

problems. Leg problems, cannot walk, can only manage one kilometer. Eye problem, cannot see too clearly,

night vision getting worse. Night vision, it’s a funny thing I was in the city one night three or four years ago. I

looked at the tram coming, capital S, I thought maybe South Melbourne. I jumped on and it was going to St

Kilda [laughs]. So I got off and walked back, crossed a dangerous intersection, got on next capital S [laughs].

South Melbourne (transcript four, page 1).

As participant four himself describes, his medical conditions were causing him significant

problems in his ability to travel around his local neighbourhood. Additionally, he had developed

chronic diarrhoea that also caused problems with his appointments and trips in the local area:
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 194

The only problem is when I have to go somewhere, when I have appointments I cannot eat because I have to

go to the toilet in the middle of the village and that’s not pleasant. That can be, uh, nasty. For appointments I

don’t go to [the] bank, I don’t eat. And when I come back from [the] bank then I eat (transcript four, page 6).

I had a little accident. Stool, you know, toilet. Hygienic duty, that’s what I’m talking about. Little accident I

had. And that’s why whenever I have appointments or something, I don’t eat until it’s over and then I eat

(transcript four, page 7).

Finally, the cognitive impact of prior overdose was an outcome of previous opiate use not

anticipated until disclosed by two participants in this study. Although cognition was not assessed as

part of the methodology of this study, repeated hypoxic brain insults as a result of opiate overdose

raise the question of long-term damage that may manifest itself in later years. For example,

participant two described overdosing during his first experimentation with heroin:

OD’ed. First hit…. Christmas Eve, 75 or 74 or something. They [friends] dumped me in a pool room, slid me

under the table (transcript two, page 8).

Participant one also described a number of opiate overdoses throughout her time using

heroin, however in contrast to participant two’s description of overdosing on his first use of heroin,

participant one described a substantial amount of time between the onset of regular use and her first

overdose. When asked if she had ever had any overdoses during her opiate use, she replied:

Yeah. 5, but only 3 hospitalised. I didn’t drop until I was about 42, and that was all to do with money as well…

I went there in the morning and the dope was extremely good back then, you know, in the 80s. And I needed a

hit in the morning to get myself together…zoomed over to their place to get a hit from them so I could get out

and get some money. And she fell out of bed to make me a hit, but couldn’t find her contact lenses. So she

made the hit anyway and gave it to me, and God knows what she put in the spoon but she must’ve filled it up,

because I put it in my arm and just went bang… (Transcript one, page 2).

From reviewing the responses to the semi-structured interview process, it is clear that the

medical conditions the participants face caused a need to adapt their daily routines to accommodate,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 195

as well as be in contact with healthcare providers on a more regular basis than they may have

needed in younger years.

Stigma.

As mentioned in the previous section, stigma from healthcare providers was a substantial

barrier to help seeking for some of the participants involved in this study, echoing findings by

Conner and Rosen (2008). Not only did stigma affect the care provided during the participant’s

older age, it had certainly shaped the experience of dealing with services throughout the lifespan.

Participant one expressed this candidly when discussing her long-term heroin use and the impact on

raising her three children. She discussed this in reference to clinical and community services she

had interactions with, believing that had her opiate use been discovered the custody of her children

would’ve been in jeopardy:

God, the minute one of those people had found out about me with 3 kids, selling smack and using, [it]

would’ve been the end (transcript one, page 4).

Further, she described situations whereby she had to make the difficult decision to either be

incarcerated or mandated to residential rehabilitation, all while attempting to maintain custody of

her children. Therefore, participant one’s daughter often cared for her two younger children while

she remained in inpatient rehabilitation. She described this situation as being driven by the fear of

losing her children:

I used it [rehabilitation] to dodge jail. But it seemed to come at the right times when I’d be on my knees

almost. And I’d… go to [rehabilitation centre]. I did a couple of stints there, one 5 months and one 6 months.

And that was a great place to go because it was… downstairs was detox and once you felt okay you went

upstairs to what they called rehab (transcript one, page 5).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 196

And she [oldest daughter] was the second mother when I’d be out of action, she’d take over, and probably

better than I did… And she did that for six months and her bloody school teachers didn’t even know, they

didn’t even pick up on [eldest daughter], that she was doing all this stuff before school and after school and

being fabulous at her school work (transcript one, page 6).

As discussed in the previous section, lifetime encounters with services that require a certain

level of mistrust and deception tend to shape an individual’s ideas around help seeking, as

demonstrated by the account of participant two, who would no longer attend general practitioners

due to perceived judgement (Sorsa & Åstedt-Kurki, 2013). Further, as described in participant

two’s background earlier in this chapter, his relapse profile tended to alienate community services

who could assist him with his psychosocial needs, such as cooking, shopping and keeping his

accommodation clean enough to avoid scrutiny and possible eviction due to his tendency to hoard

and the squalid state of the premises. Additionally, his verbal threats made social engagement in

groups outside of substance use difficult. As a result, he tended to move towards a group who

accepted him and provided charity. This group provided both psychological support and material

services that would be typically provided through a community provider. When asked if he still

associated with this group, participant two replied:

Not as much as I used to, but yeah. I go and see [devotee] every now and then and have a talk with him… If

I’ve got any worries or anything I go and talk to [devotee]. He loans me money sometimes (transcript two,

page 10).

Five of the participants in this study all suffered from some form of social isolation,

including living alone. Additionally, they were often disconnected from community groups,

services and support, either due to symptoms of their mental ill health or substance use. As

discussed earlier in this chapter, most friends and acquaintances often were involved in AOD use,

adding an extra barrier to cessation, being the loss of social networks. Participant one described a
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 197

"shunning" of non-using peers as she felt that their lack of heroin use meant a loss of a common

interest in the relationship:

Because you get, once you start using, you’re forced into a… a group of people or… you can’t mix with the

people you used to go to university with and have a job with because you’ve got nothing in common with them

(transcript one, page 3).

As she identifies, her use of heroin also forced her into a network of people who associated

through drug use. This finding reinforces the notion of addiction as career as discussed earlier in

this chapter and proposed by researchers in the addiction field. Participant one also expressed that

her heroin use had a social cost, in that she felt that she could no longer associate with people who

didn't use heroin. Further, as participant one aged, she became isolated from her friends due their

deaths from the mortality associated with heroin use and associated chronic diseases.

Social isolation amongst the participants often also had an added layer of complexity, as

discussed in the background of participant two. Not only did he isolate himself in his flat to

consume cannabis for much of the day, his accommodation was in a squalid condition. When

queried, he described having periods where he "collected" rubbish when psychiatrically unwell,

often returning to his flat after hospitalisation feeling overwhelmed about where to start cleaning it

out. When specifically asked what prevented him from cleaning his flat, participant two replied:

Um… just laziness. Look at this [gestures to flat]. I'm lazy. Most of everything that has happened in here

happened last year when I had… I schizted [sic] out, freaked out, went mad. Had my brother's car and stuff,

went out collecting junk… There's about four lawnmowers at his place that I found. That I will fix up one day.

They're easy to fix, just springs and seals and shit. That are old and worn out and need replacing (transcript

two, page 19).

In spite of identifying the difficulties associated with his living condition and collecting

rubbish, participant two still identified his collected possessions as having intrinsic value, despite
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 198

the fact that he had received warnings from his housing officer about losing his property if he did

not make efforts to remove the rubbish and attempt to clean up.

Participant five had also spent time homeless throughout his life. He highlighted an issue

that is prevalent in Australia at present, that of housing affordability (Birrell et al., 2012):

Yeah, I've been homeless. When I was homeless. You know how many people are without a flat or

accommodation? Thousands. And uh, that's why I had to stay here, because this is the only place I can afford

on the pension. I tried to sleep on the marble in the city. I put cardboard… and laid down [laughs]. Can't sleep!

Who can sleep on the cold, cold marble? (Transcript 4, page 9).

Stigma manifests in a number of ways, and the participants in this study identified

difficulties accessing services and being provided with healthcare in a non-judgmental manner.

Their AOD use was also often ignored, with them not being offered treatment or simply not

addressed as part of a holistic approach to their medical care. These issues are particularly relevant

in an older adult population, as explored in the following section.

A system not catering to older adults.

Arguably, AOD treatment services are not equipped to cater to the needs of older adults,

particularly in the home state of this study, Victoria. While older adult mental health services may

exist, the findings of this study indicate that they require improvement in identifying and providing

care to individuals with dual diagnosis. For instance, services catered to younger individuals may

require attendance at a clinic during set hours, or extensive travel. As identified in earlier sections

of this chapter, both of these conditions may be problematic, and could result in non-adherence to

treatment or relapse. Participant two, who had spent a period on a methadone maintenance program

earlier in his life, identified this point:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 199

Some days I didn't make it… [I’d be] hanging out. Go and get another taste. I missed the chemist, whatever, I'd

go and use. Nothing else to do. Otherwise you just withdraw (transcript two, page 6).

Although this scenario was identified at a younger stage of participant two's life, with a

methadone providing chemist with rigid hours and rules, he did identify that if he were to undergo

any form of substitution therapy at the current point in his life he would likely be placed in this

situation again due to a lack of motivation and organisational skills to keep appointment times.

Participant five's partner identified a point where his care changed, which coincided with a

transition from an adult mental health service to the aged psychiatry service. She expressed that she

felt that he was appointed a case manager who had more life experience, and employed a genuine

strengths-based approach to his care:

He [participant five] should be dealt with someone in his age group, and then [MAPS case manager] came out

of it which was fantastic. The [adult mental health service case manager] girl was too young to understand,

and… I think you need someone in their late 40s, or someone that’s had life experience and such, where she

just seemed like a young girl and wanted to know it all already. And maybe some things might help with the

younger kids, or certain age groups, but… (Transcript five, page 22).

And [MAPS case manager] became like a good friend… And believed [participant five] when he was speaking

to him, and didn’t treat him as if something that came out of his mouth was all just rubbish or something. That

[participant five] is a genuine person, and a person that has something to give still in this world, small or big

(transcript five, page 15).

Although it could be argued that the age of participant five's case manager is irrelevant in

this situation, the interaction does highlight the necessity of investing time to achieve genuine

rapport with consumers of mental health services, especially given the high level of complexity in

the older adult cohort. Unfortunately, this may not be possible in busy publicly funded mental

health services, or drug and alcohol services who often operate to a finite number of clinical

sessions per consumer.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 200

Four of the participants interviewed described wanting to either abstain from their substance

use, or to make changes. As discussed further in the next chapter of this thesis, services were either

not equipped to allow timely admission to act on the desire to take action, or clinicians lacked the

skills necessary to support change. This was evident from the first participant, who advised that she

had a long-term goal to cease methadone, through to participant three, who expressed bluntly:

Interviewer: Do you ever run out of dope?

Participant three: Yeah occasionally.

Interviewer: How do you find that? It must be a bit stressful if you smoke every day.

Participant three: Yeah, it is. I wish I didn’t do it.

Interviewer: Are you thinking about quitting?

Participant three: Trying to, but not succeeding (transcript three, page 5).

In terms of his cannabis consumption, participant three identified that the only help he had

received in cutting down or ceasing use was from an acupuncture practitioner. Throughout his

community health involvement his wish to reduce his cannabis use was not addressed by mental

health practitioners, and arguably would have been more difficult to address within the older adult

mental health service framework due to a lack of specialist advice for older adults with substance

use disorders.

The drug and the mental illness.

The final section of this chapter presents the results of the participant's experiences of

treatment, both from general mental health and AOD services, and MAPS specifically. The

participants provided candid accounts of their interactions with clinical services over the years, and

some offered insights into the improvement of care provision with individuals with dual diagnoses

such as themselves.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 201

Treatment experiences: mental health.

Given four of the individuals in the study had been involved with mental health services for

a substantial portion of their adult lives, they had seen a large number of changes in the provision of

mental health services, including treatments administered, settings, medications prescribed and

legislative changes that transformed the landscape of mental health care in Victoria. A similar shift

had occurred in AOD treatment settings, and although less pronounced than mental health service

changes, participants described changes in the modality of service provision in this setting as well.

These changes were explored in greater detail in Chapter Two of this thesis and were reflected in

the semi-structured interview responses provided by the participants.

Four of the participants described lengthy interactions with mental health services, spanning

their adult lives and continuing to the present day. The remaining two participants had some prior

involvement with mental health services, however this was an adjunct to their core concern of AOD

use. Participant two described long involvement with mental health services, commencing early in

his life with several admissions to psychiatric hospitals:

Yeah. Since um, the 70s… I was in Royal Park [psychiatric hospital] for about 3 or 4 months at one time

(transcript two, page 1).

Coerced treatment is at odds with the contemporary nature of AOD treatment services,

which rely heavily on a system of voluntary presentation as discussed in Chapter Two. Participant

two echoed this sentiment, describing his interactions with mental health services as being

tantamount to him having no rights:

You say you're given rights but when it comes to the crunch you've got no rights… No rights to be treated like

a human being. I got jumped on once, my sandals torn off, my shirt torn off… (Transcript two, page 1).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 202

In this example, participant two describes restrictive interventions, being physical restraint.

However, he associates removal of his possessions as a breach of his rights. Interestingly, it was

thought that his only treatment for his heavy cannabis use occurred as an inpatient of the psychiatric

facility, however he openly admitted to "stashing" smoking implements and cannabis nearby the

hospital when an admission was pending, allowing consumption of cannabis when he was granted

leave from the ward:

Yeah, it is a bit anxiety provoking [being prevented from smoking cannabis]. Like, um, there's a car park not

far from the [psychiatric hospital] that I stash all my gear in. And I go for a walk in the park and then I go over

to the car park [laughs], (transcript two, page 7).

This account seriously challenges the notion that inpatient psychiatric wards are places safe

from drug use and calls into question the clinical management of drug withdrawal on these wards,

which will be explored further in Chapter Eight (Phillips & Johnson, 2003). Participant three also

described a long history with publically funded mental health services, having a number of

admissions during his adult life: "I was in and out of hospital for 40 years," (transcript three, page

1). As discussed in the Onset section of this chapter, he commenced his use of substances while an

inpatient of a psychiatric facility. After this, he had a number of admissions for drug-induced

psychosis, which he described as not changing his drug use trajectory in any way:

No, I was diagnosed with drug-induced psychosis in 1986 and let's see… I last had the mushrooms back in

2009 so that's what, over 20 years after that I was still taking them (transcript three, page 3).

When queried, participant three reported that very little effort had been made to address his

AOD use during psychiatric admissions, only being able to recall one instance where he was told to

cease his use:

Back in about 1978 or thereabouts… one of the staff members said to me "I hope you realise you are slowly

killing yourself," (transcript three, page 15).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 203

In terms of his mental health treatment, participant three had experienced modalities of

psychiatric treatment now considered inhumane: "… back in 1968 I had the shock treatment

without anaesthetic," (transcript three, page 5). He had also experienced a long period of

incarceration in a secure psychiatric asylum in his youth. In spite of these experiences, he

recognised a positive change occurring in mental health treatment:

It seems to be improving overall, yeah. I reckon it really is improving. Like, you know the so-called

advancements in psychiatry… what's the term again, a revolution, you know. And they take into account

spirituality now, more than they have in the past (transcript three, page 6).

When interviewed, participant four echoed the sentiments of participant two, stating that he

felt mental health treatment was an infringement on his rights and freedoms. He described being

admitted during a psychotic episode, with police involvement, and summarised the issues

associated since:

Unfortunately, I was arrested by police. Unfortunately, that is how I got there, with shrinks… I tried

everything, I tried three different languages, nothing matters, nothing works at all. That's when the government

got me, and they wouldn't let me go for ever, 35 years they've been injecting me. I got tardive dyskinesia, you

know, from the injection. Tardive dyskinesia. It stopped five years ago but uh, got tardive dyskinesia…

They're wrong when they think they're right… It's a great injustice what happened to me. I believe it is an

injustice. And… what can I do? (Transcript four, page 1).

Participant four described being commenced on a depot antipsychotic injection due to non-

adherence to his oral medications, which he described as poison:

Later on they started giving me an injection. Because I refused to take a pill. Poison, poison pills, they ruin my

constitution poison pills, so I refused pills so they had to inject me (transcript four, page 1).

As presented earlier in the Onset section of this chapter, participant four attributed his heavy

drinking as a means to offset the side effects of the depot antipsychotic medication. Further, he
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 204

denied ever having his alcohol use addressed or questioned until he was transferred to MAPS upon

turning 65 years of age.

Participant five also described long involvement with public mental health services, which

culminated in him being involuntarily admitted to hospital prior to his involvement with MAPS.

Like participant three, this admission involved police attendance. He also questioned his diagnosis

and it's relationship to this admission:

I've been diagnosed as paranoid schizophrenic. But that psychiatrist had fucked right up. In that he was

referring to somebody else's file and not my file. And so, you know, when I was down here, just seeing my

ordinary GP and that, and… sorry, I'll retrace a bit. Back in Lismore, they diagnosed me as bipolar. I agree

with the bipolar aspect. But not the paranoid schizophrenic. Because I'm not paranoid about anything

(transcript five, page 4).

As discussed earlier in this chapter, participant five described his AOD use as escalating

with his elevated mood. He also recounted his admission, and his belief that it was unjust. Again,

this belief seemed to be centred around the use of restrictive and coercive force, as expressed by

participant four:

I was yelling out the back, you know, because I've got a bad back, and someone rang the ambo for us. The

ambulance. And one gentleman here, Alan [neighbour], he heard us and climbed over the fence to see if I was

okay. I said, "No I'm not Al, I need an ambulance." Then two ambulance guys turn up, and I'm about to go

with them, and all of a sudden one of them starts throwing karate punches. And I'm thinking what the fuck is

going on…. And then when I walked outside, you know, all of these policemen. And they said “Do you mind

if we put handcuffs on you?” And I said, “No, I'm a volunteer patient anyway.” And we get into the waiting

room, and I said “No needles please.” Well, due to my past history, I don't want a reoccurrence. And they

come out with a needle and all the rest of it… Well it made me angry (transcript five, page 6).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 205

In spite of this perceived ill treatment by mental health services, participant five could

identify and area for positive change in mental health inpatient units. This suggestion was drawn

from his own experiences, including what he found useful in his recovery, which will be explored

further in the next section:

I believe they need more one on one counselling. That there is a terrific lack of face to face contact, like with

the psychiatric nurses, they all seem to want to sit in meetings and discuss you, but without actually talking to

you (transcript five, page 21).

This notion will be discussed further in Chapter Eight of this thesis, however it highlights

the reactive nature of mental health services and a potential barrier to implementation of effective

AOD treatment and harm reduction on inpatient mental health wards. This section also reinforces

the differences between contemporary mental health and AOD treatment services, as discussed

earlier in Chapter Two. The next section will further expand on this contrast by presenting the

findings of the participant's accounts of AOD treatment.

Treatment experiences: AOD.

In addition to experiences with mental health service providers, four of the participants also

had been the recipients of AOD treatment service care at some point in their adult lives. Although

this has been explored briefly in previous sections of this chapter, it warrants greater investigation

due to the distinct contrast with their mental health service experiences. As discussed in the Chapter

Two of this thesis, the lack of care coordination between mental health and AOD services is a

barrier to effective dual diagnosis service provision. Participant one illustrates this point saliently,

describing little mental health service involvement but a reliance on AOD treatment services when

required:

I used it to dodge jail. But it seemed to come at the right times when I'd be on my knees almost. And I'd go to

[residential treatment service]. I did a couple of stints there, one 5 months and one 6 months. And that was a
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 206

great place to go, because it was… downstairs was detox and once you felt okay you went upstairs to what

they called rehab (transcript one, page 5).

Elaborating on this point, participant one identified that ceasing drug use was something she

preferred to do alone, relying on residential services when she felt all of her options were expended

and the custody of her children was at risk:

Back when I was a girl doing it all I was happy to have no intervention at all. I didn't want anybody near the

kids, or near my house. I was more connected to the doctor and the cops. The cops wanted me off the street

and the doctor had the place to put me. So, it was just to avoid me going to jail, and the kids then would've

been taken automatically (transcript one, page 13).

Analysing these responses, it is clear participant one seeking assistance from AOD treatment

services was driven by a form of "secondary gain:" that being avoiding imprisonment and the

subsequent loss of the custody of her children. As a result, she felt that she rarely obtained the

results she sought (abstinence) from AOD treatment services and tended to attempt to quit "cold

turkey" herself. She spoke somewhat poorly of her prior experiences with AOD treatment services:

It used to be terrible, I mean it was all based on the urine spec. We all became expert in false urines… No

treatment, I mean you were just in there to sleep and eat back in those days. But nowadays, I don’t know, I

really don’t know anymore (transcript one, page 13).

Participant five also described implementing his own plan to cease use of both injected and

ingested morphine tablets, however he sought supervision from an AOD treatment service. Despite

being an inpatient of the service and achieving his goal of ceasing use, he described immediately

"adapting" his use to cannabis on his discharge from the facility:

Participant five: I was on a pretty high daily dosage [180mg daily].

Interviewer: Did they cut you down or… just go alright, we will support you to stop?
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 207

Participant five: Yes. Support me to stop. And then they got worried themselves, you know, because

you can die from that.

Interviewer: Yeah, it's a big drop. From that to nothing.

Participant five: That took a week. Then they kept us for another few days and that. Then my mate

picked us up.

Interviewer: How did you go when you got out? Were your friends involved in drug use?

Participant five: No, but um… he had a packet of reefers lined up for us [laughs]. He said "I think

you'll need these" [laughs].

Interviewer: So you went back to smoking dope?

Participant five: Pot, yeah (transcript five, pages 12-13).

While demonstrating the importance of treating underlying mental health problems, which

participant five described as unresolved grief and depression related to the death of his partner, this

example also describes the need for follow-up care for AOD problems. Participant two also

described a switch from heroin to cannabis after being treated with methadone, which he later stated

he commenced toward the end of his methadone treatment, while attempting to titrate his dose:

Participant two: Yeah, that’s when I went on the methadone, when I was using more and more.

More than three hits a day.

Interviewer: When you went on the methadone did you keep using heroin? Some people use it to

cut down I’ve found.

Participant two: Nah, I just… I gave up using heroin. Last hit I got was a dirty hit and I was sick for

days.

Interviewer: How did you go with methadone? It can be tough to get off can’t it?

Participant two: Yeah, I got off it pretty quick. I just jumped off it. Decided I just didn’t want to be

on this shit any more. Jumped off.

Interviewer: Did you find it hard, withdrawal from methadone?

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 208

Participant two: The last 5ml was the hardest.

Interviewer: Is that what you got down to before you stopped?

Participant two: Yeah. Like I know guys that will get down to 5 or 10mls and hang out and start

using again. And, uh, you’ll see them 12 months later they’re still on their 10mls or

5mls. They can’t get off it.

Interviewer: Why did you find it so hard, the last 5?

Participant two: Well my bones started aching. All of my bones started aching.

Interviewer: Was it similar to withdrawing from heroin given they’re similar drugs?

Participant two: Yeah. [It] Was a withdrawal (transcript two, pages 12-13).

Participant two's history demonstrates the complexity inherent in individuals with dual

diagnosis. It also again demonstrates the concept of adaptive use, in this instance the use of

cannabis to ameliorate the withdrawal symptoms of a drug used as opiate replacement therapy

(methadone).

This section demonstrates the difference between AOD treatment and mental health

services, with participants generally describing their AOD treatment as brief interactions during

their lives. Conversely, mental health services were often involved for a substantial amount of time,

and often involuntarily. The next section of this chapter outlines the participant's experiences with

MAPS, the older adult mental health service that is the focus of this study.

Treatment experiences: MAPS.

The final section of this chapter describes the participant's experiences of care being

provided for them by the Caulfield Hospital MAPS, the service that is the focus of this study. This

section forms a companion to the previous two sections, being treatment from other mental health
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 209

and AOD agencies, and is intended to complement these sections by comparing current experiences

of treatment. Four of the participants described their experiences with MAPS as positive, with the

remaining two expressing concern at coercive care, as indicated earlier in this chapter. Participant

one, who was new to the public mental health system when referred to MAPS, stated:

Well I'd never met them before, but they've been wonderful. And totally non-judgmental about drugs

(transcript one, page 9).

Participant one described this non-judgmental attitude as being important to her and a key

reason for her engaging in mental health care from the service. Participant three echoed this

sentiment, describing periods where abstinence was the default expectation for individuals with

dual diagnosis:

They don't come down on you these days. They haven't come down on me like a tonne of bricks (transcript

three, page 15).

Despite participant three expressing a dislike for a stern approach, participant five felt as

though this was essential in his care. He reported his case manager using this approach, using the

physical damage heavy AOD use was causing him as a pivotal reflection to aid him in changing his

behaviour:

Interviewer: So it sounds like you've had positive experiences with [case manager} and MAPS.

What has [case manager] done to help you change?

Participant five: Yeah, he helped me out with my sister and her hand in my finances. Yeah.

Interviewer: It sounds like he's helped you change your thinking around drug and alcohol use as

well though.

Participant five: Yeah. Yeah, he's been pretty heavy with me on the alcohol.

Interviewer: Heavy?
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 210

Participant five: Saying that my liver is damaged and that I need to take more care of myself, rather

than binge drinking and that.

Interviewer: Is that something that you feel has worked for you? Because some people… when

people come down heavy on them, they don't want to know.

Participant five: Yeah (transcript five, page 14).

However, while participant two attributed a direct approach from his case manager to

enabling change and reminding him of the negative consequences of his heavy alcohol

consumption, participant six likened such a strategy as a misunderstanding of his reasons for

alcohol consumption, namely being to control ruminating thoughts to allow sleep. He referred to his

perceived belief that his case manager did not approve of his current alcohol intake, rationalising it

as a misunderstanding of his belief that alcohol was therapeutic in his situation:

I don’t think he’s [case manager] told me directly, he has said you know what harm could come. And I say

what harm, like Freddy Mercury, who wants to live forever? I don’t so much disagree with what he is telling

me. The normal reaction to the alcohol, what I disagree is to the point that he doesn’t understand that I’m very

healthy and it’s not as if I’m leading in to anything else. I’ll be honest with you, very honest with you. If you

could give me temazepam of a night, and I knew I could go to sleep, I would stay with the temazepam. So

what do you become addicted to, the temaz or the brandy? Yes, that’s right, okay it’s being dependent, but it is

doing the job. There is nothing worse, I can tell you… than to just be lying there for hour after hour and not

going anywhere (transcript six, pages 10-11).

This interaction demonstrates the skill needed to address problematic AOD use, particularly

in providing feedback around ambivalence to change, support with use of medications that may

cause dependency (such as benzodiazepines in this case), and to assist participant six to maintain a

level of controlled drinking that is acceptable to both himself and mitigates the risks to his health.

This section has served to describe the experiences of the participants in seeking help and

treatment from both mental health and AOD treatment services. It also identifies a changing
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 211

landscape in mental health services, however the absence of accounts of participants engaging in

treatment with AOD services in their older years is telling.

Summary

The responses presented in this chapter indicate that the individuals who agreed to

participate in this phase of the research were not a homogenous group as previously discussed in

Chapter Three; rather, they were diverse individuals, with differing mental health problems, choice

of substance, medical comorbidities and other complexities. Although drawn from a small pool of

participants, these responses demonstrate the issues specific to the older adult dual diagnosis cohort.

They were also a difficult cohort to access, namely due to the small sample available from those

being case managed by MAPS at the time and issues associated with access as discussed in the

fourth chapter of this thesis. The next chapter of presents the findings of the qualitative interview

process conducted with clinicians who provide care to older adults with dual diagnosis.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 212

Chapter Seven

Phase Three: Findings From Staff Interviews

Introduction

This chapter presents the results of the final phase of the study, which interviewed case

managers and clinicians from Caulfield Hospital MAPS to ascertain their experiences in working

with older adults with dual diagnosis. This chapter was inspired by the work of Deans and Soar

(2005), who interviewed a number of clinicians working with dual diagnosis clients in rural

Victoria, Australia. Their research found clinicians describing a number of frustrations and barriers

present in providing care to individuals with dual diagnosis, and it was felt when planning this study

that a critical appraisal of these issues should be conducted. In addition, the spirit of the explanatory

sequential model guided the semi-structured questioning instrument utilized in this chapter (Mason,

2006). A number of themes emerged during the process of interviewing clinicians, with the themes

involving the challenges and complexities involved in providing care for older adults with dual

diagnosis. Additionally, clinicians were also asked to identify areas for improvement in providing

care for this cohort. These findings are detailed throughout this chapter.

The Third Phase

As identified in the previous chapter of this thesis, this research was conducted under an

explanatory sequential framework with each phase informed by its predecessor. In this instance, a

qualitative chapter exploring the experiences of clinicians became essential to provide both depth

and context to the previous two phases of the research. It became clear during both the file audit

process and interviews with consumers that clinician experiences and influences on the care of

older adults with dual diagnosis were an essential element of this thesis. Accordingly, this phase
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 213

was informed by the two phases preceding it as is required in an explanatory sequential design

(Stange et al., 1994).

The participants involved in this phase of the thesis had a wide range of experience, ranging

from two to approximately 30 years. This phase interviewed five registered nurses, two social

workers, an occupational therapist, a psychologist and a carer consultant. MAPS employed all

clinicians interviewed at the time of interview, and a semi-structured interview tool was utilised

during the process.

Content Analysis

Content analysis for this section was conducted in a similar manner described in Chapter

Six. Interviews were transcribed and imported into NVivo prior to content being examined for

themes. Three key themes emerged during this process, being assessment and response, clinician

experiences and service collaboration. Each of the three themes identified has a number of sub

themes which are presented in the following sections.

Assessment and response.

Assessment of any potential presenting health concern is a cornerstone of care planning by

healthcare professionals, both to recognise individuals presenting with the concern and to determine

the severity of the problem (Sobell, Sobell, & Nirenberg, 1988). Alcohol and other drug problems

are not immune from the need for screening, with several excellent screens available (Bright, Fink,

Beck, Gabriel, & Singh, 2013; Dawe et al., 2003; Hirata et al., 2001). In addition to the use of

formalised screening, clinicians typically employ clinical judgment and reasoning to identify

clinical problems and apply clinical reasoning to formulate treatment plans. This section explores

the issues associated with both assessment of older adults presenting to MAPS with dual diagnosis,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 214

and once identified, the service response issues as identified by a number of clinicians of the

service.

Assessment issues.

As indicated in the introductory paragraph of this section, assessment of alcohol and other

drug use is a critical function for services to correctly identify and enact treatment planning in older

adults with dual diagnosis. Despite the recognition of dual diagnosis and the relative uniformity of

screening and assessment procedures for AOD use in this setting, many clinicians described either

not being trained in using tools such as the ASSIST or being instructed to utilise brief approaches as

part of an overall initial assessment package. Participant one, a registered nurse with a number of

years’ experience in MAPS, felt that this issue had been apparent for some time:

And that’s been a long-standing issue. And if they do drug and alcohol, and yes there is an issue, but that is as

far as it goes. So… it’s usually only those where [AOD use] is quite obvious. As to going the next step… even

talking to them about, you know, what they’re doing, how they find it, have they ever done this, what’s their

history with drug and alcohol. It’s very poorly managed. And not seen as enough importance. The mental state

has always been the issue, but not relating it to the drug and alcohol (transcript one, page two).

In addition, when queried about the introduction of the ASSIST, participant one identified

that it was rejected as an assessment tool with the preference being a short screening instrument

embedded into a generalist assessment package. This is particularly concerning, given the parent

health service identifies the use of the ASSIST as essential to dual diagnosis competency:

… It’s never been accepted as being what we use… the only one [screening instrument] we used here was a

really short questionnaire… are you using or do you use, how often and how much, and do you think you have

a problem. That was it, it was a four question thing that we tried to even bring in just for all case managers

(transcript one, page one).

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Further, participant one clearly articulated the issues associated with a piecemeal approach

to asking about AOD use as opposed to the use of a uniform screening instrument. In the following

passage, participant one expresses an opinion regarding the current state of identification of AOD

use, being confined to instances where it is voluntarily disclosed or “obvious” visually during initial

interactions with the consumer:

I think the main thing is to recognise that it’s something that we need to be aware of with everybody that we

go and visit, and that everyone we visit… is assessed for it. To screen it, because it’s only when you actually

ask when you find out. And most of the time most people don’t ask, it’s either the only time they ask is if it’s

volunteered to them, or if it’s pretty obvious when you go and visit someone and they’re out of it. So I think

just getting that off the ground would make a huge difference. So it has to be just a part of your initial

assessment, your everyday assessments, always. And I think until then, it just won’t happen. It has to be seen

as mandatory, as part of doing a mental state and doing a mini mental [state examination], (transcript one page

seven).

Participant two felt that the lack of a standardised screening approach left clinicians in the

situation where they were required to ask questions perceived as difficult or uncomfortable,

providing an alternate explanation as to the apparent reluctance to discuss AOD with consumers.

Participant two felt this was particularly evident with new graduate (“grad”) clinicians, and that

assessment required training in discussing issues such as this with consumers:

We don’t even ask about their usage, let alone what they want to do about it. So I think as a service we really

need to go back to basics and work out, and train us in how to have those conversations with people. Because I

think that, I mean I’ve been working in this area for over 20 years, so I feel quite comfortable just having that

conversation, but I know in my supervision of lots of new grads, but also reasonably experienced people they

are still really uncomfortable asking about mental state and risk and suicide, and you know, relationships and

drug use. There is lots of stuff we don’t talk about because people are personally uncomfortable (transcript

two, pages 5-6).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 216

In spite of the example of having a conversation around alcohol and other drugs being

related to difficulties in neophyte clinicians, participant 10, who carried a number of years in both

mental health and MAPS, identified instances where she felt she had ignored screening due to the

lack of obvious cues towards AOD use:

I’ve caught myself a few times when I’ve just assumed that there is no history and then I may not even go into

that section, that part at all, because I assume (transcript 10, page 1).

As mentioned in Chapter Five of this thesis, the section of the electronic assessment

document participant ten is referring to is an arbitrary question related to the presence of AOD use.

Participant ten also identified two key perceived issues which were echoed by other clinicians

during the semi-structured interview process, being a feeling that assessing for AOD was just

another burden in an already overwhelming assessment process, and a lack of rapport at the initial

contact stage making asking questions about AOD use difficult:

I think part of the problem is the assessment because there is so many other things, it shouldn’t be too difficult

to ask those questions, but I think that sometimes that is what stops me. Not having that rapport (transcript 10,

page 2).

Participant ten also echoed sentiments present in the literature and explored in Chapter

Three, being a perception that older adults simply don’t use illicit drugs:

Alcohol I will ask, heroin I would never ask about, no. Not in aged psychiatry (transcript 10, page 6).

Clearly, this finding also raises issues concerning exploration of an AOD use history, a

pivotal function of tools such as the ASSIST (Humeniuk et al., 2008). Again, it should be noted that

AOD use can often be fluid, with individuals moving in and out of use and changing substances

over time, highlighting the importance of exploring historical AOD use. Not asking may mean

ongoing use could remain covert, as identified by participant six:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 217

… It’s very easily overlooked when you have more psychiatric conditions you focus on, and then it may easily

be forgotten if it is not in the forefront. But unless you really explore that bit you will not get to know unless it

is very obvious and you fall over the bottles when you enter someone’s flat. The baby boomers are getting into

the age range now… And they very often have dabbled in it, but some have hung on to illicit drug use

(transcript six, pages 1-2) .

Despite the notion that illicit drugs may be going undetected due to a reluctance to discuss

use with consumers, participant seven felt that this was not the case due to the nature of illicit

substances often being clearly observed or openly disclosed at the point of assessment. She felt

discussions around alcohol were lacking in the service:

I don’t think we ask the question often enough. I think we kind of gloss over it a bit. I think alcohol is the one

we fall down on. I think we’d be good if someone said they were on marijuana or heroin or something like

that, but I think because booze is so acceptable, we don’t fully get the impact it has on people’s lives

(transcript seven, page 1).

When considering assessment for AOD use, issues were identified regarding rapport and

self-report, which often manifested as an assumption that individuals would not report AOD use.

This often resulted in a reluctance to raise the issue of AOD use in assessment. For instance,

participant five, when queried about the presence of a screening tool in the service, replied:

I think it was the ASSIST. How often would you use it, how many do you have, and then I think how does it

affect you, does it stop you doing stuff. I forget to ask about that. But they are usually going to say no anyway

(transcript five, page 1).

The final sentence of this response is discussed in Chapter Three, with the ongoing

discussion around the validity of self-report. Participant eight, who worked as a carer consultant and

spent much time with families, felt that this could be addressed through her ability to attain

collateral history during the initial assessment. She also felt that this collateral would be difficult to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 218

obtain for a case manager, echoing participant ten’s notion of attaining adequate rapport before

attempting to discuss AOD use:

I think the carer consultant should come out to assessments… To meet as early on in the consulting process

with the case managers, because there will be a lot of collateral that the family and carers will give the carer

consultant that they wont think to give to a case manager (transcript eight, page 4).

Although this section demonstrates a lack of uniform, comprehensive screening, a

reluctance to approach the topic, and perceived issues with self-report, it is worthy of completing

this section with a quote from participant five, which is self-explanatory in terms of it’s worth in

this clinical space:

We are not really having that conversation, and most of them aren’t going to bring it up themselves. So

perhaps it’s the conversation that we need to take responsibility for starting (transcript five, page 2).

Cultural considerations.

In an organisational sense, culture can be defined as “… a system of interrelated and

interdependent habit patterns of response,” (Wiley, 1929, cited in Kroeber & Kluckhohn, 1952, p.

61). In respect of the semi-structured interview process with clinicians, a theme developed where

participants discussed the need to lead from above when it came to providing dual diagnosis

competency. These comments echoed the 2007 Key Directions document published by the

Victorian State Government, which suggested “While the dual diagnosis initiatives have raised

awareness of the necessity for service development, the responsibility for further development now

sits with the leadership in each mental health and alcohol and other drug service,” (p. 18).

In respect of the notion of leadership, participants felt that clinical leaders within the MAPS

service should be driving dual diagnosis competency as a service priority. This was described by
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 219

participant two, who expressed that introducing a new line of assessment (and therefore work)

needed to be driven by service leadership to become “core business:”

I mean if we are going to be pursuing a certain line of assessment, you are only going to seek out the ones that

you have to do. There is so much paperwork as it is that we are not going to seek out, I want to do a whole

extra tool for that when we don’t have to. So, absolutely, it’s a top down issue, if it’s a service priority it needs

to be a service priority. It’s not going to come from the case managers on the ground (transcript two, page 2).

Although this paragraph raises workload concerns, which will be addressed separately in a

later section of this chapter, it also describes the need for service priorities to be clearly defined.

Participant two further elaborated on this statement, expressing a belief that the service was still

preoccupied with definitions of mental health that tended to exclude AOD use:

And I think that is top down, that’s a service leadership issue… we are still focussed on just the mental health

part of the person… I see that this service is very much still focussed on mental health and sees drug and

alcohol as separate (transcript two, page 4).

In recognising an organisational culture shift in regard to dual diagnosis practice, participant

three identified that attempts had been made in the past to identify areas of practice that were felt to

require attention, with a feeling that these were merely a short term focus rather than a sustained

change in competencies:

I think there is more emphasis on it [dual diagnosis], but I think it’s like sometimes you think these sorts of

things they become the flavour of the month, like it might be dual diagnosis one year, and agoraphobia the

next year and the importance of picking up that as related to people becoming depressed. I think in psychiatry

things often come in and out of vogue, but having said that that is not to devalue the importance of it. Because

it is important (transcript three, page 1).

Participant seven felt that a realisation that managing complex dual diagnosis would force a

paradigm shift, resulting in recognition that dual diagnosis competent practice would reduce the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 220

financial burden on healthcare services, as well as the burden on consumers who continue to use

drugs and alcohol with devastating physical consequences:

I think it probably has to start at a far higher level. I think somebody one day, a bean counter, will wake up and

think this is going to cost us a lot of money. And, you know, we need to target it. It has to be, even if it is not

from the money, it is the quality of life. People lose everything, their dignity… it’s awful (transcript seven,

page 9).

Further, participant seven described the difficulties in managing consumers with dual

diagnosis and complex needs, and emphasised the value of support to clinicians in the service, in

addition to recognising the efforts clinicians were making in working with this cohort:

I think education, I think support, I think it has to come from on high. You know, I think people need to be

supported on it. I guess having somebody like you who has got focus in that area. And acknowledging the

work that gets done with people (transcript seven, page 9).

While acknowledging the need for cultural change, participant nine also emphasised that

change also needed to come from the bottom up, as in clinicians working directly with consumers:

I think there needs to be systemic change from top down and bottom up. I think that we could do more in terms

of education and make it more of a focus of our assessment (transcript nine, page 2).

These comments emphasise those in the previous section, where hesitation, a lack of

rapport, and a perceived level of discomfort made asking about AOD difficult. Interestingly,

participant six related this to a fear of change, with a perception that many clinicians felt a level of

comfort with their present abilities, and the introduction of new skills bringing a degree of

resistance:

It’s only the theory the dual diagnosis stuff. It came from the top, but if someone has only been working in one

field for many years… be honest, [people] don’t like that much change. They think they are good at what they
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 221

are doing, they’re doing it in a similar way, perfecting what they have been doing before (transcript six, page

7).

Perhaps the most pertinent comment was made by participant ten, who stated:

You have to have support of the management. Because otherwise it’s not going to happen (transcript ten, page

10).

The discourse in this section illustrates the need for systemic change to be supported by

clinical leaders in the service, as opposed to being issued as a service directive with no active

support or future evaluation. Consequently, these responses demonstrate the need for cultural

change, incorporating an awareness of, and support for, dual diagnosis competency in MAPS.

Cultural change also demonstrates a need to recognise that dual diagnosis is the work of a

contemporary older adult mental health service, as discussed in the next section.

"Not our business."

The "no wrong door" policy was formulated to ensure individuals with dual diagnosis

referred to either AOD or mental health treatment services received adequate assessment, treatment

and/or referral rather than being told they were not appropriate candidates for the service in

question (McDermott & Pyett, 1993). Despite this noble aim, clinicians described instances where

individuals who presented predominantly with AOD issues did not proceed past the referral stage to

assessment and case management by MAPS. This appeared to be a case of older adults with AOD

being "not our business," as described by participant two:

I think it's been very tokenistic in this service… this is a government directive that we are going to be no

wrong door, we will accept anybody. But it hasn't really been taken up by this service. And certainly, if

someone rang here on intake and I took a referral that was just centered around drug and alcohol issues it
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 222

would be knocked back in handover the next morning. There is no doubt in my mind. So it's quite tokenistic at

this point I think (transcript two, page 10).

Further elaborating on this point, participant two described her predicted trajectory of a

typical referral with a significant AOD component being rejected during a handover meeting:

I reckon if I took a referral this afternoon that was for someone who was presenting to their family aggro

because they're taking ice, what do you reckon would happen in handover the next morning? I reckon they'd

say, "That's not us, no way." I really think that the services still operate that you absolutely need to have a

primary mental health diagnosis to get in the door (transcript two, page 10).

The concept of a requirement for a primary mental illness to not only be present, but be the

chief complaint of individuals referred to MAPS for assessment was reiterated by participant one,

who described dismissal of referrals due to consumers being seen as primarily AOD users, rather

than needing mental health services to make substantive recovery gains:

It's sort of seen as two separate things, or they're just dismissed as "oh, well they've always been a drinker, so

of course they're going to be, you know… sort of devalued a little bit I guess (transcript one, page 3).

Participant two went on to discuss her reasoning behind the apparent reluctance to accept

referrals where AOD issues were predominant:

I think when the comment is "it's not depression or it's not this, it's because he drinks, and if he stopped

drinking he'd be fine." So I think it's that either or, we drop the ball then, and I've seen that happen with a few

people. And I don't know if it's because they’re too hard, I guess (transcript two, page 4).

Participant eight described a story of working with a client's daughter in her role as carer

consultant that underscores the reluctance of accepting individuals with predominant AOD issues.

In this instance, the consumer had been abstinent from alcohol for some time, however both
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 223

participant eight and the consumer's daughter had discussed a perceived reluctance to provide case

management:

At the time she [consumer's daughter] felt there was some resistance from the service for her taking on her

father at home. And there was also the feeling at the time that he would fall off the wagon again pretty quickly,

and that it was futile (transcript eight, page 3).

Participant seven, who reported that she felt that the use of alcohol often excluded

individuals from further involvement with the service, also discussed this perceived reluctance:

I think there is an attitude that if somebody is drunk, or they've been drinking we won't see them. How often do

we get people who are referred, and we just say well if they are drinking they're drinking and there is not much

we can do about it. You know, if they're using substances there is not much we can do about it. And I think

there is a reluctance to jump in (transcript seven, page 1).

Participant seven, who worked in the role of sole clinical psychologist for MAPS, went on

to discuss addressing the causative factors of substance use disorders, particularly alcohol. She felt

that investing time in treating the underlying mental health issues was a worthy use of service time:

Let's treat them and see what happens. Instead of putting our hands in the air and saying oh well, they were

intoxicated, they were this and we can't do anything for them (transcript seven, page 10).

The idea of treating AOD as a mental health issue as opposed to a dichotomy was also

discussed by participant nine, who felt that there was little to separate AOD and mental health

issues. He summarises this statement by describing a lack of action to incorporate dual diagnosis

practice into daily clinical activities:

I think that it is a significant mental health issue or has mental health sequelae so I think that perhaps we can

be more proactive in working with these dual diagnosis clients. To keep them on the books. And not say look it

is drug and alcohol, it's not our bag… But I don't think that we're actively changing our systems in order to

make our assessments and clinical judgments better. We are not kind of pursuing education or anything

(transcript nine, page 2).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 224

As referrals for care are received by MAPS, the no wrong door approach indicates that those

refused should be referred on to appropriate services; however, participant one expressed a lack of

support around providing referral to services that may be better geared to accept individuals with

primary AOD concerns:

But a lot of the time here, when you bought it up, it was well that's not really our role… it wasn't supported

very much in our system either to facilitate links to those services (transcript one, page 4).

In summarising the issues associated with treating dual diagnosis as "not our business,"

participant two stated:

… When I first started working it was always mental health and drug and alcohol are separate. And, you know,

one has nothing to do with the other, and if people have drug and alcohol issues they go away and do it

somewhere else (transcript two, page 1).

The no wrong door policy attempts to provide care for individuals presenting to a service

regardless of whether it is their core business or not. It is clear from the participant's discussions of

the acceptance of referrals with an AOD component that individuals were not being assessed due to

the presence of AOD use and a belief that these presentations are not the work of a contemporary

older adult mental health service. This discussion also touches on educational preparation of

clinicians working with the dual diagnosis cohort, which will be explored fully in the next section.

Educational preparedness.

Throughout the semi-structured interview process, participants spoke of feeling unprepared

to provide care to consumers with complex dual diagnosis needs. Predominantly, this related to a

perceived lack of educational preparation, both pre-registration and during their professional

practice. This finding was similar to the work of Deans and Soar (2005), who found in their

research that working with dual diagnosis clients was perceived by clinicians to involve a high level

of knowledge and skill. Participant nine, who described attending various sessions of theoretical
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 225

education largely lacking in strategies he felt were practical, described the need for exposure to

clinical situations to improve capability to work with older adults with dual diagnosis:

I've been to a couple of education sessions and you can hear the theory all you want, I think at the end of the

day it's getting your nose in there and working with them that is going to improve [your practice], (transcript

nine, page 5).

Participant nine expanded on this statement, describing his experiences of attending a

workshop marketed as being specific to older adults with substance use disorders:

… Well one of the things that I wanted from going to the dual diagnosis education… was some assessment

tools that were brushed over, we really didn't talk about them as much as I wanted so I felt disappointed by that

and I think that is something that I would probably use if I had them available. Much like I routinely use the

MMSE to test cognition if that was an issue, yeah, I think that could be used (transcript nine, page 7).

Participant two, who felt that one-off training sessions were inadequate without the requisite

organisational change required to make dual diagnosis prominent in both clinical discussions and

day-to-day clinical work, shared this sentiment:

I think that a day’s training… unless you are applying it, unless you’re using it in real situations, it is

meaningless. And so I think someone [with a dual diagnosis focus] being in the clinical review, prompting and

asking questions and supporting people, because I don’t think the management here are at all expert in this

area. So it doesn’t come up from them. It’s not an issue for them. So I think having someone within the team

being a reminder and being a prompt for people. And giving us tips and ideas of how to manage people.

Because I don’t think we have that, we don’t have the core (transcript two, page 9).

The description of training whereby the focus was not on practicalities is linked directly to

the first sub-theme of this section, being issues related to assessment. In fact, this was a common

theme throughout discussions with case managers in the semi-structured interview process, with a

realisation that a lack of educational preparation in applying sensitive and timely screening
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 226

techniques apparent. Participant one reinforced this observation, describing educational preparation

as being essential to the recognition of substance use disorders in the initial assessment stage:

And I guess that's the other thing with case managers, education… And it has to be first of all on getting

people familiar with it, like what do they assess for, what do they look for, what are the risks, you know, those

sorts of things. And not seeing it as separate from physical and mental health, because you've got to do all

three (transcript one, page 8).

Again, a theme in this discussion was a reflection of recognising substance use disorders as

not distinct from mental and physical ill health, rather identifying that AOD use is integral to a

holistic assessment of a consumer. The notion of holism was also discussed by participant seven,

who identified the overall effect a substance use disorder could play in a reduction of an

individual’s quality of life and the importance of being able to identify AOD use in treatment

planning:

Assess better, much more education around assessing. Asking the question. And I think much more education

to us about the impact it can have on people. People just think liver disease or whatever, it doesn’t matter. But

I don’t know that people fully understand how badly it can affect somebody’s quality of life. Because you are

not necessarily going to die, you could live for quite a while (transcript seven, page 9).

At times, a lack of educational preparedness manifested during discussions as a feeling of

helplessness. This notion will be discussed further in the next section, however participant three

described feeling as if the service was doing everything it could within the confines of its

knowledge and skill base, yet expressed some helplessness in being unaware whether more could be

offered:

I think we could probably manage them better. I don’t think we are as skilled up as we probably should be.

Look, I think they’re identified and plans are made and we discuss them at reviews, but I don’t know if there is

more that we could be doing. It might be, I guess I’m not availed to that knowledge I suppose (transcript three,

page 2).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 227

Participant three went on to elaborate further, recognising the need not only for ongoing

education but a standardised approach to caring for the dual diagnosis cohort in the service:

Because we are not really armed up with anything at all, formally. And informally it’s what you pick up in

your experience. It would be good to have better guidelines… just good education. Good practical education

too, stuff you can use (transcript three, page 10).

Participant six also expressed the concept of past experience shaping ability to work

competently with the dual diagnosis client cohort. This was also a frank statement that not

everybody may be equipped with the experience to manage complex dual diagnosis:

Well, that would be depending on the individual clinician. I don’t think we have sufficient training in the area,

or sufficient discussion... But I would say it’s really dependent on the experience, what you’ve had and been

doing before you came into this job, [and] I think the experience may vary considerably within the team

(transcript six, page 1).

While this statement may be considered somewhat dismissive of the power of educational

preparedness to provide the skills necessary to both assess and manage substance use disorders in a

mental health setting, it lends well to a statement made by participant five, who felt that discussion

around how people worked successfully with the dual diagnosis cohort was an essential part of role

modelling capability:

Just hearing about how different people work with people with these sort of issues would be useful. More of

those, like when we have case discussions we’re not really doing that. We’re not really saying how do you do

it, we are saying this is their problem, this is what’s happened, this is where they’ve moved on. But we are not

really saying this is how we do what we do, even generally, even in other areas… I’d like more practical

strategies and stuff like that (transcript five, page 8).

This section represents a group of clinicians who expressed a lack of practical education

regarding both AOD use in older adults and dual diagnosis more specifically. These representations
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 228

are likely representative of the growing concern of a lack of training in AOD issues in both

undergraduate education and non-specialist postgraduate programs tailored to clinicians (de

Crespigny, 1996). The next theme explores specific issues arising during the semi-structured

interview process related to the experiences of clinicians working with older adults with dual

diagnosis in MAPS.

Clinician experiences.

Throughout the semi-structured interview process that formed the basis of this phase,

clinicians described their experiences of working with older adults with dual diagnosis. This was

encouraged through focussed questioning and allowing clinicians to reflect on their past

experiences of working with consumers with co-occurring substance use disorders as a means to

identify current working practices and to enable clinicians to outline potential areas of service

improvement. The following section explores the sub themes that emerged from the content

analysis process related to clinician’s experiences.

Clinical experience.

During the semi-structured interview process, clinicians identified a number of prior

experiences they had working with consumers with dual diagnosis. In spite of a lack of formal

training, these experiences often involved a measure of using initiative and clinical judgement in

working with consumers with dual diagnosis. It was also apparent that a number of these former

experiences shaped their methodology and future interactions with dual diagnosis consumers.

Despite describing their clinical experiences with dual diagnosis consumers as being mostly

positive, there was a measure of apprehension that working with co-occurring AOD issues as being

“different” to clients without substance use disorders, as expressed by participant ten:

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 229

It’s a difficult area… in mental health we can be very paternalistic, you know, and tell people what has to

happen. It’s a very different approach to drug and alcohol where you have to work with the client. It’s just the

culture of working is very different (transcript ten, page 8).

The notion of a substantive difference between mental health presentations and those

involving an AOD use component was reflected by participant six, who expressed a belief that this

was an extension of the theory that motivation is a requirement to successfully treat individuals with

dual diagnosis:

… You only succeed if they really want to make change, so it comes up to the participation of the patient

themselves. Their desire, what they want to achieve. So… motivating them and trying to give them goals

which are achievable (transcript six, page 3).

Throughout the interview process, clinicians reported using goal setting as a means of

formulating treatment plans for consumers with dual diagnosis. They described a number of

measures aimed at involving consumers in their treatment from the initial point of recognition of a

substance use disorder, as described by participant nine:

I suppose just kind of developing a good rapport with the client from a harm minimisation approach, saying

let’s work together to see what risks there are and what we can do to reduce them, or what you are interested in

doing to reduce them. That’s I guess where I work from as a staging point, keeping that level of trust and

openness going is important (transcript nine, page 6).

Of note is the reference made to a harm minimization approach, a model that was supported

by a number of participants. Despite fleeting references to abstinence as a means to improve health,

many participants approached consumers with co-occurring AOD use from a harm minimization

perspective. This was expressed by participant two through recounting an interaction with a client

during her clinical practice, which also describes the application of a strengths-based approach to

treatment planning:
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Like the time I told you about before when I was sitting in the front garden with the bloke smoking a joint…

the conversation I did have with him was first of all it was like “oh my god, that’s not a cigarette is it”

[laughs]. That was my first, but then it would be tell me about how much. I would have a conversation about

what he is doing and how much he is doing, and how it is impacting his life I guess. Because the other thing I

always think as an OT [occupational therapist] is people like this man, who is quite impaired through long

term mental illness, must have a whole heap of skills associated with sourcing and getting drugs [laughs]. So

that’s the other thing I always think about, like how and what and when and why and how that can be positive

for them in other areas of their life. Because that really fascinates me, that the occupation of sourcing and

getting drugs and paying for them, and managing to pay for them within the other constraints of your pension

shows a lot of skills. So I often have that conversation with people as well. And how you can use those skills in

other ways, rather than the harm that has been done (transcript two, page 7).

This narrative by participant two mirrors the notion of addiction as career, as discussed in

Chapter Four, recognising the transferability of skills associated with a career in AOD use to those

in so-called “normal” worlds. Participant two went on to elaborate:

So that’s one way I usually, that’s one conversation I have with people. Like… sourcing those drugs, you are

able to do this, this, this, this and this, how else can we use those skills with you. And then, yeah, just the

conversation about do you want to change anything, and if you do what do you reckon we could do? And even

cutting down, you know, once a day rather than three times a day, or twice a week rather than five times a

week, that sort of conversation. But that’s all just intuitive, I’ve never had any training in any of that (transcript

two, page 8).

A strengths-based approach to care is steeped in the clinical application of holism or seeing

an individual as a complex entity as opposed to a disease process (Gelkopf et al., 2016). It

recognizes that all individuals have skills despite mental ill health or AOD use and seeks

opportunity to integrate all aspects of care in the treatment plan. The notion of holism was

summarised well by participant one:

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… Physical stuff, physical health, addressing all of those things. Diet, all of the complementary things that go

around promoting their own wellbeing or health for a start. All those sorts of things. So you look at all of the

different stressors that they are under, and you try and work with those. Alcohol wise, I guess… it depends on

finances, so it’s looking at those sorts of things, things you can put in place to minimise access, to minimise

capacity to get it, all that sort of stuff. Their support networks, who they’re with, those sorts of things. Because

very often their social networks also revolve around drug and alcohol. So how do you… deal with that as

well? That’s very difficult (transcript one, page 6).

Participant seven, who believed taking an approach of educating the consumer in regard to

their AOD use was far more successful in motivating reductions in use rather than dictating

advocacy, also described this:

And so I don’t think we provide enough education about what it [AOD use] does, and I think it comes across

as judgment and we are spoil sports and we are taking away their fun. Whereas if it is just put in pure clinical

terms, about this is it and this is why we care, then maybe people would be more open to it. And we should

approach it that way, you know, we should see it that way as well. I think that would make it easier for people

to ask the question (transcript seven, page 3).

Challenges specific to the older adult cohort had also been encountered by participants, with

participant four describing a nursing home assessment she felt frustrating from a clinical

perspective, with the situation apparently using alcohol as a tool to moderate problematic

behaviours:

Participant four: Here’s an example, today I went out to do an initial assessment in a nursing home.

The lady can’t walk, doesn’t leave and has no visitors, but is still smashing

[drinking] a bottle of wine a day. It’s the staff there that are giving it to her, and she

has her first one after breakfast.

Interviewer: Has she got a long history of drinking?

Participant four: No, this is new.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 232

Interviewer: So what’s the reasoning behind that?

Participant four: Well, she’s now paraplegic, and has no social supports, no family and her husband

has died. She had a significant suicide attempt and is now replacing this with

alcohol. Self-medicating so is refusing to take any actual medication but is

[drinking] a bottle of wine. That’s what we are up against [laughs]. Giving someone

with borderline [personality disorder] a bottle of wine a day, and they wonder why

there are behavioural issues (transcript three, page 6).

This example illustrates a number of complex issues in conjunction with problematic

alcohol use, including a late onset of alcohol use disorder, grief related to loss and maladaptive

coping to a number of significant life events. In spite of describing mostly positive interactions with

consumers with dual diagnosis, there were a number of key issues emerging in the discussion.

These issues are explored further in the next section describing clinical helplessness.

Clinical helplessness.

In spite of participants describing sound methodologies in working with older adults with

dual diagnosis, particularly in relation to harm minimisation and a holistic approach to care, a

prominent theme expressed during the semi-structured interview process was that of clinical

helplessness: participants often described frustration at perceived slow progress, or a feeling that

they should be doing more to help the consumer address the AOD component of their presentation

while they were providing an active case management or clinical role. Participant ten expressed this

during her interview:

There is this feeling of helplessness when you deal with people, because there is this expectation that it is

going to be impossible to change the behaviours (transcript ten, page 10).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 233

Participant seven elaborated further on this point, describing a process of judgement of

consumers referred to the service with AOD issues, and a feeling that ongoing use of AOD was

deemed a failure and led clinicians to feel as if their efforts were worthless:

I think people just judge them, I think it’s an automatic thing. I mean, you know, you talk about people will

they drink, won’t they drink again, will they use, won’t they use again… you know, our automatic response is

that they will, and I guess the likelihood is that they will. But there is also this kind of thing where, I guess,

because the stereotype is that these people will always use and do they tell you the truth, or if somebody says

they have five drinks they’ve probably been having double and all this kind of thing. So there’s that kind of,

you know, you don’t want to be duped, you don’t want to be the idiot who is out there doing everything for

this person and all of a sudden you find out that they are using, they are drinking (transcript seven, page 2).

Participant seven went on to describe a perception that dual diagnosis consumers were

viewed as being difficult to treat and case manage, leading to a perception that clinicians were

“admitting defeat” without appraising the impact of ill mental health on their presentation:

I do think there is a tendency again for us to put it into the too hard basket. And sometimes… their substance

use seems to be the thing that comes to the surface more rather than looking at the mental health issue as

well, and they often tend to get lost to the service (transcript seven, page 4).

Conversely, participant five described a feeling of helplessness when case managing

individuals who were experiencing both the deleterious physical and cognitive effects of AOD use

yet expressing little real motivation to make changes to their use:

It’s I suppose a lot of it’s ethical, like how much do you let people keep on poisoning themselves and so on.

Sometimes we do say look you can’t go on doing this, and this is what it’s doing to you and sometimes you do

need to say it that way (transcript five, page 3).

This discussion raises an interesting point around the conundrum associated with merely

providing supportive case management and seeing an individual continue to use AOD as opposed to

assertive, abstinence-based methods. Although this is a discussion beyond the scope of this section,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 234

it is worth noting that it contrasts harshly with most healthcare disciplines, who base their

profession on helping and treating disease (White & Evans, 2014). Often, in both mental health and

AOD settings, this phenomenon is pitched as a lack of insight into the disease process or condition

preventing the individual from making changes despite all of the evidence against continuing use or

reluctance to undertake treatment. During the interview process, participant six described this:

But to get them to acknowledge that they should address that issue… remains a challenge. Like we have in

only psychiatric patients when they don’t develop any insight into the need for treatment and stopping, starting

treatment and therefore the outcome is compromised for them. That they see that they need treatment, it’s the

same with dual diagnosis. To address your drug and alcohol issues you need to be having the insight that you

would benefit from addressing the issue. And it’s not easy to achieve (transcript six, page 2).

Participant three spent some time during the interview process discussing a consumer he had

case managed for a number of years who continued to use heavy amounts of alcohol despite the

impact this was having on his mental and physical health. A high degree of clinical helplessness

was observed in this interaction:

I don’t know whether he is managed well, but he’s surviving and doing the best he can. He remains alcohol

dependent, but it’s basically harm minimisation with him. And that’s been more or less successful. But I think

you’ve always got this feeling that you’d like to be able to do more with him, but it’s very difficult to instill

that sort of self-motivation (transcript three, page 2).

Participant three’s expression of wanting to be able to do more emerged during another

discussion concerning the consumer in question, who was described as spending time looking for

remnants in discarded beer bottles on a busy nightlife street in Melbourne:

And I suppose it’s the whole there is nothing much I can do, but I still do think occasionally it is pretty awful.

When he talks about “I had a really good night the other night, I found half a bottle of beer” you think poor

bugger, no, this is… this is awful (transcript three, page 7).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 235

Further, participant three described his efforts to date to attempt to both motivate the

consumer to change his behaviour, in addition to providing a form of harm reduction and degree of

safety around the consumer:

…We’ve tried [financial administration]. You get three lots of money… three separate payments over three

times a week to minimise it so you don’t spend it in one hit, but I mean he still spends it in one hit over those

three days. When it’s gone for grog and cigarettes, that’s it. And then you think what else can you do, and he

doesn’t want to change it, so what can you do? And then I get his flat, I’ll get that cleaned up with [industrial

cleaning service] twice a year with them. Completely done, and then it just starts to pile up with bottles and

junk. You know, rubbish and stuff. Because you think if his environment is better, maybe he will respond to it.

He does, but it just doesn’t last. So there are some people that you just can’t reach in that respect. He says he’s

a vagabond, “I’m a vagabond… you know me. I’ve always been a vagabond.” And you think, oh, that’s a

shame (transcript three, page 8).

In the aforementioned paragraph, it is clear that participant three has tried a number of

methods to attempt to attain change of the consumer’s ongoing AOD use with little success, and is

now employing a reactive strategy. Clinical helplessness in working with consumers with dual

diagnoses does not only lead to frustration within clinicians, but also can lead to therapeutic

nihilism (Alonzo, 1993). This will be discussed in the next section.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 236

Therapeutic nihilism.

Therapeutic nihilism, defined by Starr (1976) as the notion that medical treatment is

ineffective in certain situations and therefore more benefit is gained from doing nothing, is a logical

outcome of the feeling of clinical helplessness expressed by participants in the second phase of this

thesis. In terms of dual diagnosis, therapeutic nihilism often manifests as the provision of reactive

case management that makes no real effort to address the co-occurring substance use disorder. This

may arise for a number of reasons, including the lack of skills to address AOD use, a view that the

behaviours may be longstanding and therefore not modifiable or as a result of the theme of the

previous section, clinical helplessness. The view that AOD can often not be modified due to

entrenched use was expressed by participant ten:

I think in aged psychiatry it can be difficult because it is such a long history. I think we make assumptions

about motivation to change their habit… I think we just accept that it is a longstanding problem and there is

not much more that we can do (transcript ten, page 2).

Participant four expressed perceived difficulty in working with consumers in the service

with alcohol use, chiefly due to fluctuating motivation. She went on to describe this frustration as

being present in clinical interactions, a potential source of therapeutic nihilism:

I’ve always found it strange working with people with alcohol dependence, I mean you can have all the best

intentions of helping them, but until they want to help themselves it’s too hard, and their insight fluctuates so

much. Today they want help and tomorrow they want nothing to do with you. And that can be in your head as

well, when all you want to do is help somebody and they continuously throw it back in your face (transcript

three, page 8).

In fact, participant nine described a degree of therapeutic nihilism when discussing a

consumer he had been case managing for some time. The consumer had a complex psychosocial

history, heavy cannabis use, and with relapse often characterized by threatening and aggressive

behaviour and had been transferred from an adult community mental health service to MAPS a few
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 237

months prior to the third phase of this thesis. When queried as to whether there may be a tendency

to manage consumers such as this at “arm’s length,” participant nine replied:

You are exactly right, and I do have thoughts every time I drive back from South Melbourne visiting him…

whether I need to, or could be more involved or assertive in helping him… I know that he has expressed from

what I read in the notes that there is some motivation to cease. However it seems to me to be such a big part of

his life, and I suppose I’ve kind of had that attitude where well, you know, that’s one problem that I can’t

solve. Let me focus on things that I perhaps can help with… But I guess it depends on where you set the bar,

doesn’t it? And I don’t know if that sounds pessimistic to say so, but I suppose it is just pragmatic and realistic,

and I don’t expect that I am going to be able to save [consumer] from his substance use or from himself. You

know, he’s had a pretty rough upbringing, and he still lives in a pretty dire social situation. So… I kind of

accept that his substance use probably contributes to his mental state and his poor functioning I think. It’s an

underlying issue that might actually be a support for him, and a very strong support for him, not only in terms

of the pharmacological effects of the drug, but also in terms of the social networks that it provides for him.

While I don’t know it from an objective sense if they are the most supportive and functional social networks,

they are social networks nonetheless, and without it he wouldn’t have them (transcript nine, pages 4-5).

It is interesting to note in this discussion that the participant describes preservation of

networks involved in drug use as a social support for the consumer in spite of perceived impacts on

cognition and mental health. Participant seven, who echoed the opening sentiments of this section,

being that dual diagnosis is often seen as being too hard to address, also mentioned this:

I think it will just be seen as being too hard. You know, it’s a bit soul destroying, what can you do, it’s their

choice to drink, it’s their choice to do whatever they want to do. But their quality of life… and there is no

effort to find out why [they do it], (transcript seven, page 2).

Other participants frankly described a degree of therapeutic nihilism in their interactions

with consumers with dual diagnosis, as evidenced by participant two who felt this occurred more

frequently in her practice with illicit drug users:

Perhaps not alcohol, because alcohol issues are more obvious, and… people are used to older people drinking,

they’re not used to older people taking other substances. They are starting to trickle in, and I’ve noticed on
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 238

intake and we’ve spoken about, you know, ice featuring here and there… I think even there was someone in

the waiting room earlier today that’s got a long and colourful drug history, and I used to case manage him and

I never really attended to that. Although one time I turned up for a usual case management visit and he is

smoking a joint in the front garden of the SRS he lives in. So, really there and in my face, and I was aware of

it, but never really attended to it in a structured way as part of the case management. At all (transcript two,

page 2).

Therapeutic nihilism is an ever-present clinical challenge in the care of individuals with dual

diagnosis, and older adults are no exception. Therapeutic nihilism leaves alcohol and other drug use

unaddressed, virtually treating mental ill health and substance use disorders as two separate entities

rather than attempting integrated treatment, widely viewed as current best practice in treating dual

diagnosis (Ouimette et al., 2007).

Family and carer issues.

During phase three of this thesis, participation was sought from the carer consultant at

MAPS. The carer consultant role aims to facilitate linkage and open communication to consumer’s

families by MAPS and achieves this aim through an individual with lived experience of a family

member with mental ill health. In this case, participant eight served as the carer consultant for

MAPS and was interviewed during the process to obtain a “family-centric” perspective of the issues

relating to families of consumers with dual diagnosis. Participant eight described her understanding

of the genesis of the carer consultant role, which she felt was born out of frustration from careers:

From not being recognised as carers, as the primary carer. Not being heard, not being asked what their

knowledge of the person is and the history. It’s better now, particularly with the new mental health care act of

2014 because carers are more involved. And there is a sense of failure, that they are embarrassed because they

feel they have failed their relative with a mental illness so they don’t want to talk to the case manager because

they feel they will be blamed. So that’s where the carer consultant will come in having the lived experience

and say well hang on, I know what you mean, but that’s not what they would think. They’re non-judgmental,

and they are there to get the best for your loved one. So it gives another perspective (transcript eight, page 4).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 239

Participant eight, whose own lived experience was caring for her daughter with dual

diagnosis, was able to relate to the frustration evident in interactions with clinicians and the service

in general, and felt that an open, transparent approach in communication with families was essential

in her role:

… Families will give up. And yet, if they understood, for instance if I’d have know really early on with my

daughter… that this was going to be longer than just one inpatient admission it would’ve been really useful.

For me, we weren’t told that this was actually going to be as long. They didn’t have to say definitely, they

could’ve said there is a possibility that this is going to be a bit of a journey, a life journey. And that would be

useful, because then having said that then we’ll say well what do we do? So then that’s where you would kick

in with strategies, I would kick in with strategies of how I’ve managed it. And we may have been able to keep

my daughter well, as well as she can be. And I think for a lot of carers, need to know that they need to look

after themselves. For instance in this cohort of carers a lot of them gave up their jobs years ago to look after

their unwell relative. Which we do not advocate at all, we say do not give up your life. You do them as much

as you can and you draw on the services. So things like that, this should not alter your life, you still deserve a

life. You’ve got to… if your [relative] ends up in aged psychiatry you do not visit every day. You take care of

yourself because the lead up to admission would’ve been exhausting for you. So these are things I think would

be really useful (transcript eight, pages 7-8).

Despite the vital role the carer consultant played in the MAPS service, it was still felt to be

perceived as a fringe role rather than as a clinical one. This was evident with participant eight’s

description of being told not to attend clinical reviews, where initial assessments, new consumers

and ongoing discussion around longstanding consumers occurred:

Well, I think it would be great, because a lot of the time families of these people with dual diagnosis have

burnt their bridges. But there is some part of the family that is trying to hold on often. For example

[consumer], his brother tries so hard and I think we can connect well. I think I keep saying to him just hold on

there, it’s great, and I think it gives them hope that, you know, they are not being ignored, that their needs are

being understood. That they are not just being looked at as being families that don’t care, it’s more that I can

really relate to them that yeah it is hard, but it’s great if you keep being involved. So I think that’s really
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 240

important. So where I think I would step in, is if I came to the review every Thursday… I would hear about

families (transcript eight, page 2).

Participant eight also felt she could perform a valuable role during assessments, introducing

herself to families early and assisting with gathering vital collateral history from significant others:

I think the carer consultant should come out to assessments when there is a family involved, regardless of

whether… and introduced, that’s a big thing for me. To meet as early on in the consulting process with the

case managers, because there will be a lot of collateral that the family and carers will give the carer consultant

that they wont think to give to a case manager. So I think that would work well (transcript eight, page 4).

During the interview, participant eight went on to describe her work with a family of a

consumer with dual diagnosis. The discussion has been included here to provide context and

indicate the importance of providing liaison to families in older adult mental health settings:

Interviewer: What are some of the issues he has faced?

Participant eight: So what [the brother] has faced is verbal abuse to his partner.

Interviewer: From [consumer]?

Participant eight: From [consumer]. And possibly non-consideration about when he turns up to the house,

there are no boundaries from [consumer’s] side. So he will turn up and ask for money, not

that [brother] resents that, but it’s more the entitlement, I think. You know, he’s my brother,

I’m going to do this and I’m going to do that. So yeah, I think it’s more often the person with

the mental health, the dual diagnosis lacks any understanding of boundaries, and that can

often drive families away. And I think the verbal abuse, which hasn’t been more lately I

don’t think, having been in contact with [brother] has been useful I think, because it has kept

some sort of involvement with [consumer]. At least I can say yeah I know what that’s like,

have you tried this strategy.

Interviewer: Has he ever mentioned what keeps him involved?

Participant eight: A sense of loyalty, a sense of family. [Brother] grieves a lot for what his family… he grieves

a lot for the past, and I think he remembers [consumer] as being a beaut young boy, as a
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 241

brother. I think siblings, because siblings know each other the longest of any relationship, I

think there is a lot of loyalty there. And sadness, because I think their background was pretty

tough going, so I think that also [brother] knows that [consumer] had a bit of a rough go in

some ways. So yeah, those sort of things.

Interviewer: Okay. So what would you provide for [brother]?

Participant eight: Yep, well for [brother] I just say to him if you, we struck this sort of deal that if went and

took say [consumer] out for lunch to one of these lunches in St Kilda, and [consumer] was

particularly difficult. And if we worked out a day that I was here, he could come straight

over and he could debrief with me. That’s one that I think is really important, so he can just

go I don’t see why I bother, and I would just listen. And that’s half the time all that people

need. I give him contact, I gave him Mind, Carers Vic, free counselling, the six free

counselling [sessions] that you can get. GP mental health care plan, things that… [brother]

didn’t realise existed. I also say to him you ring me any time, and I’ll ring you back, and if

you are having a particularly difficult time I will either pass it on to [case manager] or

whoever is involved. Or we can talk it out (transcript eight, pages 2-3).

This section indicates the vital role a consumer consultant plays in working as a team

providing care for older adults with dual diagnosis. It also indicates a number of concerns, such as

access being blocked and ultimately making referral to the role significantly more difficult. This

situation needs urgent remedy given the current awareness of family involvement in caring for

individuals with dual diagnosis (Menicucci, Wermuth, & Sorensen, 1988; Mueser & Fox, 2002).

Service collaboration.

The final section in this paragraph describes issues arising from the semi-structured

interview process related to service collaboration, being the ability of the service to work with other

services to achieve suitable treatment for consumers with dual diagnosis. It discusses issues arising

from referral processes, a pressure to discharge consumers felt to be “AOD only,” and collaboration
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with AOD treatment services to achieve suitable outcomes. It concludes with analysis of responses

from participants relating to their suggestions to improve the dual diagnosis capability of MAPS.

Discharge pressure.

During the semi-structured interview process underpinning the third phase of this thesis,

there was a predominant theme related to dual diagnosis consumers being “not our business.” This

theme was that of pressure to discharge consumers with substance use disorders from the MAPS

caseload quickly due to an overarching feel that they were not appropriate for mental health case

management. This was described succinctly by participant seven, who stated:

Because what can we do for them? You know what I mean, [it’s] that kind of attitude, what can we do. It’s

their choice, their decision (transcript seven, page 1).

The notion that there is a choice in being dual diagnosis resonates strongly with the themes

of clinical helplessness and therapeutic nihilism, where clinicians can justify reactive approaches to

case management and making little attempt to address AOD use by describing consumers as poorly

motivated, lacking insight or persisting with entrenched behaviours. This also appeared to translate

to those consumers making incremental gains, as described by participant nine:

In fact there has been this flavour of managing this particular client… that we have to rationalise keeping this

person on our service. Because their recovery goal is a substance use issue, and even though they’ve had a

career of 50 years of substance use she is arguably making small gains. But I guess we feel like there is some

resistance for keeping her on for that reason, I guess from a medically driven psychiatric service there has been

some resistance (transcript nine, page 3).

When exploring the perception of pressure to discharge, participants in this phase did not

agree with discharging consumers quickly. Conversely, they felt consumers should be given time to

address goals and provide space to work towards sustainable change, leading to the conclusion that
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 243

discharge pressure was being driven at senior levels of the service. Again, participant nine describes

the benefit of being able to work with this consumer long term:

I think that we have been able to stay in there for the long term with this lady, and I think that has been

valuable for her as well because we are making small gains. I suppose at the end of the day, as much as I talk

about resistance from the service, we have been given enough rope to do what we believe is good for the

client, what we want to do. If we are able to, and if the client is engaging and they are kind of showing even…

they are showing motivation, even though they might be fluctuating. Yes, and I think that from what I do know

from drug and alcohol it is a fluctuating picture and you do need to work in the long haul (transcript nine, page

4).

Participant seven affirmed this point in her interview when discussing this consumer. Both

participant nine and participant seven had provided joint clinical services (case management and

psychology) to this consumer:

Oh yeah, lots of pressure to discharge. Where is the end point, you know? I wasn’t letting go (transcript seven,

page 5).

Of note is participant seven’s reluctance to “let go,” which demonstrates that clinicians were

prepared to advocate for their consumers to remain on their caseload. Further, when discussing

pressure to discharge consumers from the service, participant two was asked directly if she felt that

presenting a consumer with strict AOD goals, for example reducing alcohol consumption from

three standard drinks daily to one, would be supported in continuing to be case managed by MAPS:

Depends on the team. This team, not necessarily. Not necessarily… I don’t think we’d be encouraged to just

for that purpose. If there were other mental health goals and recovery goals associated with pure mental health

yes, but if you said this is my only goal with this person I’m not sure whether that would be supported

(transcript two, page 8).

This was supported by participant one, who when questioned about the presence of

discharge pressure related to consumers perceived as having predominantly AOD issues replied:
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If you’re trying to reduce their alcohol, yes I think so, and if they’re compliant with that. But I think as soon as

there is, you know, there’s backwards and forwards movement that is typical, I don’t know how much it would

be tolerated by a service like us holding them on as a case management [consumer], (transcript one, page 5).

In spite of recognition that dual diagnosis involves two components that need to be treated

as interrelated, there was still evidence that this was not occurring in MAPS. Consumers were felt

to be “not our business” even after being accepted by the service and were then discharged

accordingly. This was also discussed by participant ten, who stated:

We often will try to treat, engage the person to treat depression, but if… we look at which is the more likely

problem. And if it is that alcohol is the predominant issue then it often happens that we will say that it is not

appropriate for us (transcript ten, page 4).

This statement is in direct conflict with the aims of the Victorian Government Key

Directions (2007) document, which aimed to make dual diagnosis core business. Given the

evidence of the pressure to discharge clients from MAPS, it is apparent that this is not occurring.

During this phase, it also became evident that consumers were not being provided with referral to

AOD treatment services, as discussed in the next section.

Referral difficulty.

As described in the previous section, pressure to discharge consumers from the MAPS

caseload was evident during attempts to provide care for individuals with dual diagnosis.

Additionally, further questioning around this topic during the semi-structured interview process

reflected what was found during the first phase of the project: a distinct lack of knowledge of AOD

services, leading to no outgoing referrals even if they were in the best interest of the client.

Participant one also felt this was the case, stating:

I don’t think people are aware enough of the referral pathways. And I know in the past we’ve had problems

with accessing the Dandenong [inpatient detox unit]. It was always an issue. And I don’t know if that still
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 245

exists. But I know in the past it was very difficult to get people there, and very difficult to even get them

assessed (transcript one, page 3).

This response demonstrates a perception that AOD services may be unhelpful with the dual

diagnosis consumer cohort, as indicated by participant one’s description of a previous interaction

and attempt to secure care for an individual. This may also be a reflection of the issues associated

with age, particularly given the perception that it is difficult to attain services for individuals once

they reach age 65. This seems to be discerned from the mental health system, where plentiful

services exist for those under 65, however aged psychiatric services become the sole “owner” of

individuals once they reach this age. Participant six described this phenomenon as follows:

The problem is with the age group. So for example, withdrawal services often have age limits of 65. I find that

probably inappropriate given that people with drug and alcohol can easily be over 65, so what service and

linkages post MAPS involvement… I think that is a service difficulty in general which is not really addressed.

I think the service model that we have in Victoria leaves that too unaddressed (transcript six, pages 2-3).

Although this was felt to be a barrier to referring to appropriate services, clinicians also felt

at a loss to describe the referral process and which service they would refer to for ongoing AOD

support if required. This finding was despite attempts at improving access in a significant service

reform in Victoria (Department of Health, 2013d), and was expressed by participant four when

queried if she knew where to consider referring a consumer with AOD issues who required ongoing

care:

Well not really, because I haven’t referred anybody to those services yet. But I feel pretty confident that if I

bought it to the team that other people would know and be able to support me in that (transcript three, page 2).

Again, although this passage indicates deficiencies in the referral process, it does

demonstrate that clinicians were prepared to collaborate with their peers and discuss ongoing

referral within the wider team for advice. Although this would assist with actually making a
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 246

referral, participant five reinforced the need for research to determine the most appropriate service

for the consumer:

It’s hard, you have to kind of remember which ones they are and work out which is the most appropriate, so

that would… take a little bit of finding out which is the best one. And I’ve since got on to, what’s it called…

South City [AOD clinic], that one, and [consumer] didn’t want to go so that didn’t work very well. Because

they want people who are really motivated, but… I think so (transcript five, page 5).

This conversation also echoes statements discussed in the previous section related to

motivation, or more specifically the perception of clients being motivated to want to make changes

to their AOD use. Even if motivated, a lengthy wait list may stand in front of a consumer in need of

AOD treatment (Redko, Rapp, & Carlson, 2006), or an appropriate service simply may not exist.

Participant nine illustrated this conundrum when describing one of his consumers who he felt would

benefit from the Older Wiser Lifestyles program described in Chapter Two of this thesis. This

program, like MAPS, operates in a finite geographical catchment area and therefore excludes

MAPS consumers:

I really feel that we are at a loss not to have someone like the [Older Wiser Lifestyles] program here, in this

area. And I have a bloke who has an alcohol use disorder and he… he was contemplative and he actually made

some good efforts to reduce his alcohol after the diagnosis of cognitive decline. I gave him some materials

from [Older Wiser Lifestyles] that he said were very interesting and helpful. But I got the sense that he didn’t

qualify to receive their services from the clinician, I feel he would do well (transcript nine, page 6).

This section demonstrates ongoing problems with the referral process, which ultimately

resulted in very few ongoing referrals for AOD treatment as found during the file audit process

conducted in Phase One of this thesis. A lack of awareness about referral pathways was evident

through analysis of the discourse surrounding this topic in the semi-structured interview process and

will be discussed further in the next section dealing with intersectorial collaboration.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 247

Intersectorial collaboration.

This section describes intersectorial collaboration, more specifically cooperation between

mental health and AOD treatment services. During the interview process, clinicians bemoaned the

lack of cooperation between both services, which were felt to work in isolation rather than in any

attempt at integrated treatment. As discussed in both Chapter Two and Three of this thesis, this split

in service provision appears to have occurred during the process of deinstitutionalisation, which

resulted in services becoming “specialised” and effectively limiting their target groups. Participant

one described this as follows:

It was always integrated when I did my psych training, it was just seen as normal to do drug and alcohol, and

everyone knew where to refer, where to get someone detoxed and you’d pick them up again once they were

detoxed for casework. You worked hand in hand with drug and alcohol services. And it was part of our

rotation when we were training. I worked at the Smith Street clinic at Collingwood as my placement. It was

part of it, you just did drug and alcohol placement (transcript one, page 3).

The value of reciprocal rotations was highlighted earlier in this chapter by participant six,

who spoke of clinicians bringing varied experiences from a variety of sources and workplaces.

Participant six elaborated further on sharing knowledge between services:

I think we should have more exchange in education and case presentation… I think the drug and alcohol

service can contribute to educating and helping our dual diagnosis challenges and vice versa, the psychiatric

challenges. So I think to get everybody comfortable in addressing dual diagnosis issues we need to work close

together (transcript six, page 3).

He went further to discuss reciprocal rotations and the benefit to both the clinician and

service, which directly supports the narrative of participant one at the beginning of this section. It is

noteworthy that this was a goal of the Key Directions document (Victorian Government Department

of Human Services, 2007), and has been described as a method to obtain true dual diagnosis

competency by other authors (Australian Healthcare Associates, 2011; Kenneth Minkoff & Cline,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 248

2006). As discussed in Chapter Two, secondments of this nature have been largely unsuccessful,

leading participant six to recommend they be made compulsory:

We need to have compulsory secondments, I think, in different areas. That would be beneficial, okay you have

to work three months in a drug and alcohol service to get more exposure to that issue and then you can bring

that expertise, what you’ve learned back to your psychiatric service and vice versa (transcript six, page 4).

Short of compulsory secondment arrangements, participants lamented the lack of

intersectorial collaboration between services and felt that an opportunity to discuss roles, modes and

methods of operation would be a good start to attain better working relationships, as expressed by

participant four:

It would be helpful as well if people from those services came in and spoke to us, and explained the protocol

for the referrals and what they actually do there, and who is appropriate for the service (transcript three, page

5).

Interestingly, participant four directly mentions referrals, which are noted to be a source of

difficulty for clinicians. This was described by participant two, who stated:

… As an intake worker I don’t know enough about the services that are available (transcript two, page 7).

This statement goes some way to add context to the results of the first phase of this study,

where it was noted that no referrals for ongoing care were documented at the point of assessment.

Clinicians may have been unsure or unaware of appropriate services. This issue was discussed in

the previous section; however it is clear that formalised linkages between services would not only

make the referral process easier, but assist with the sharing of knowledge and allow clinicians to

build trust in both their colleagues and services decision making capability. Participant three

lamented the lack of linkages between MAPS and AOD services as follows:

… We certainly need some links. Because we don’t have any links whatsoever really, we’ve only got what we

learn from each other I reckon. You hear have you tried this, have you tried that (transcript three, page 5).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 249

Not only would linkages allow a form of “facilitated” referral, but also knowledge sharing.

However, participant seven felt that AOD services had a distinct lack of knowledge and clinical

interest in caring for adults over 65, as the majority of their work had been with people younger

than this age:

And I think the other thing is though to be honest, I don’t think they are very knowledgeable about our age

group. Because the focus, why has the focus always been on people under 65 drinking and… why do services

think that somebody when they hit a certain age, I mean this is the time when a lot of people take it up. And it

is when it is most, just as dangerous. And it’s going to, in fact the health burden and the cost to society will

become greater and greater, because they have all these cognitive issues. All these people who will be living

longer, because physically they are healthier, and… they are just going to cost more and more. And I’ve seen I

don’t know how many people on the wards recently with hepatic encephalitis because of booze. A man just

recently [and] a young woman not 50, and they are in hospital for weeks. They go home and they will be back

in. Their quality of life is stuffed (transcript seven, page 7).

This conversation adds context to the urgency required in addressing the issues associated

with dual diagnosis in older adults, and although this section describes the participant’s discussion

of the merits and virtues of better linkages to AOD services, it also demonstrates that older adults

may not present via means associated with traditional AOD services. They also may lack the

capacity to meet consumers where they require care. The following section, the final theme of this

chapter, presents the participants’ suggestions for service improvement.

Improvements to service delivery.

The final section of this chapter presents discourse surrounding improvements to service

delivery. During the interviews comprising the third phase of this project, clinicians often described

ways they felt MAPS could be improved when considering the care of consumers with dual

diagnosis. These suggestions for improvement largely mirror the issues arising through the course

of this research project, and are presented here.

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The concept of clinical supervision is one that has attained much research interest in mental

health nursing circles. Clinical supervision provides a forum to discuss issues arising in clinical

practice and gives the opportunity to formulate strategies to provide care to consumers (Roche,

Todd, & O'Connor, 2007). Participant one felt that clinical supervision was lacking, and outlined

her perceived benefits:

I think that [clinical supervision] would be really good, because if you don’t… because it is, it’s just building

confidence in case managers to have skills. Because a lot of people don’t know how to manage it or the only

way to manage it is they have to stop them. That there is nothing in between, you know, like it’s either you

can’t do anything, or… There’s no understanding of harm minimisation, there’s no understanding of those

current sort of ways of managing (transcript one, page 8).

This paragraph raises some interesting questions related to building skills in clinicians to

utilise harm minimisation approaches rather than dictating abstinence as the default stance on AOD

components of a consumer’s presentation. Additionally, there is an ideology here that the support of

an experienced clinician in this setting would build confidence in clinicians. Following on from this

statement, MAPS potential to handle an influx of consumers with dual diagnosis was discussed

with participant one, who replied:

We would only go alright if people were given the right tools to do it, and that is assessment tools. The

knowledge and support to manage people like that. Otherwise it will just fail. Fail miserably. And because

people with dual diagnosis pick up if people aren’t interested, you’ve got to have people who have an interest

in it as well. Because a lot of people don’t feel comfortable working with people with dual diagnosis. A lot of

people have got fairly biased attitudes or prejudices against people with dual diagnosis too. Which comes

across [laughs]. You hear it all the time, and I think that’s a problem. Huge problem. And until that’s

addressed too, yeah (transcript one, page 9).

Participant seven also raised the need for support and a team approach, which is in

contradiction to the current MAPS model of one case manager to one consumer. Given the acuity
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and complexity of consumers with dual diagnosis, this brings into question whether a sole clinician

can actually achieve satisfactory outcomes without the support and assistance of a team approach:

I mean, you have to have a team of people to work with somebody like that. Because as well as that it is

difficult for the person, because it is slow and you do need that kind of debriefing and that ability to go and

talk to somebody and say “oh, you know, this happened or that happened or am I doing the right thing,” or

whatever. You need that, you need that support. Because… if my best efforts have, you know, I think am I

being duped, heroin, oh what are these addicts. You still have prejudices. I have to work very actively to make

sure I keep them in perspective. Because it’s very hard not to. But it’s a team, I think it’s a team approach, you

need support, ideally (transcript seven, pages 5-6) .

In addition to a one case manager to one consumer approach, there was also a push at

MAPS to ensure case managers were exposed to every type of presentation to maintain skills. This

model of generic case management was questioned by participant two, who felt that it led to a loss

of skills due to attempts to try and maintain competency in every possible presentation to the

service:

I think that you lose it in these generic roles. And I’ve been guilty of that in the past, I’ve been guilty of losing

my discipline in trying to manage everything that you’re trying to manage as a case manager. But I also think

that before we get to that point you also need to have some… Yeah, I think that the way mental health has

gone a lot of the positions are generic so you can lose your discipline let alone pursue specifics, like alcohol…

particularly if you’ve got a caseload where people can be quite acute. You’re just dealing with what’s in your

face a the time, so you really don’t have time to deal with, you know, recovery focused OT practice or really

focus on the alcohol and drug issues. You’re just dealing with what’s in your face at the time. So I reckon

that’s a real problem with… the way the system is going, that everyone is generic (transcript two, pages 3-4).

This passage raises not only the issue of generic roles being a danger to discipline specific

skills, but also raises the possibility of a specialist worker providing both support and specialist

skills to those with dual diagnosis. This role may also assist to cultivate competency in dual

diagnosis, a concern expressed by participant six when questioned about the readiness of MAPS to

accept a potential influx of new dual diagnosis consumers:

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I wouldn’t describe us as a competent dual diagnosis service. So any increase of anything will be a challenge.

So if we are not doing the few ones who are easily identified not really making it an integral part of our

discussion, when things become more difficult and the baby boomers with a lot of drug and alcohol issues we

get through, I don’t think we are that well prepared. Only theoretically prepared (transcript six, page 6).

Echoing the concerns surrounding an ageing baby boomer cohort and their potential to

create significant service pressure, participant ten stated:

This issue, and it is going to become bigger, there are so many people that the culture of wine drinking… and

you know, people drink it at dangerous levels. And daily. And not realising, you know, and after so many

years of doing that they are going to come to us (transcript ten, page 9).

In respect of problematic drinking, the cause is often left unaddressed while administering

treatment, instead focussing on physical measures such as safe detox and pharmacological methods

to manage craving, anxiety and low mood. Participant seven felt it was imperative that treatment

involved efforts to address the root causes of AOD use when working with consumers with dual

diagnosis:

From people’s wellbeing, and I think a lot more awareness of asking the why question, you know, why do you,

especially I think with drink more than other drugs. But why, why do you drink heavily? What’s going on

underneath that maybe we could help you with? You know, and I guess it’s a little bit like if we get someone

in who is quite forgetful that we think is depressed, we treat the depression. In the same way we should be

looking at people who are drinking and thinking, you know, there is a strong chance there is depression

underlying this (transcript seven, page 10).

Finally, participant eight, who functioned in the carer consultant role, felt it would be

beneficial to include families through education. She described a format of providing information

evenings at another service she was employed by, and felt this would be beneficial for families of

MAPS consumers:
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I could start to hold support groups, or information days from a carer’s perspective. Here in MAPS. Have an

afternoon, it might work, it might fail. I think information nights are fantastic. At Orygen [mental health

service] we have what we call family and friends. They are run about four times per year… We attend most of

them, the family peer support workers, so we go along, and it is all for family and friends that have got either

people in the inpatient unit or in the outpatient clinics. And the first one is where the case manager just talks

about what would be dual diagnosis, what it means, how it impacts. Second one a doctor comes in, or could be

the case manager who talks about medications and ways of managing the medications where the families fit in.

We are there, and at break we always talk to the clients. Then the third night is simply for carer support, we

just run the whole thing. And then on the fourth night, which was new and very popular, SUMMIT came in

and talked to these families about drug and alcohol use. Which we’ve been dying for them to do because it’s so

big. So I think something like that here might start off slowly but I think it would be fantastic. So that’s one,

information night support group, that I think not so much for… I think you’d have to be careful, because

families, although with the older age group they are retired so it could be a good thing with the carers, whereas

with the young people the carers tend to work. So that would be an evening thing. But here I think it would be

worthwhile trying, support groups (transcript eight, pages 6-7).

Summary

This chapter has presented the results of the third phase of this research project, where

clinicians were asked to describe their experiences of providing care to consumers of MAPS with

dual diagnosis. The clinicians involved in the third phase of this research project formulated

worthwhile and valuable suggestions to improve the provision of care to older adults with dual

diagnosis. Their ideas, which mainly revolve around collaboration, support and education, would be

cost effective to implement and would improve the care of dual diagnosis consumers immensely.

These suggestions, and other recommendations for service improvement, are discussed further in

Chapter Nine.
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Chapter Eight

Discussion and Implications

Introduction

This research project has explored the complex phenomenon of dual diagnosis in older

adults. The first phase of the project sought to determine the prevalence of dual diagnosis in older

adults assessed by the Caulfield Hospital MAPS community mental health service. The second and

third phases of the project sought to narrate the experiences of both consumers with dual diagnosis

and the clinicians who provide care to them respectively. This chapter aims to discuss these results

in the context of the implications of the findings of this study, both to inform contemporary practice

and provide evidence for further research.

Discussion

During the analysis of the results emerging from both the quantitative and qualitative phases

of this study, four key points emerged. These points were the deficiencies in screening and

assessment of older adults with dual diagnosis, older adults with dual diagnosis being a poorly

understood population, the notion of complexity, workforce readiness and system response. These

points will be discussed separately in the following sections.

Deficiencies in screening and assessment.

Chapter five of this thesis sought to determine the prevalence of dual diagnosis in the MAPS

service through the use of a file audit methodology. This process reviewed two years of initial

assessments conducted by MAPS clinicians, and as a result, provided a succinct overview of the

assessment process being conducted by the service. This overview revealed substantial deficiencies
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 255

with the nature of the assessment process for alcohol and other drugs; the lack of a standardised

screening tool for AOD may go some way to explain the substantial prevalence gap between this

study and the work of Blixen, McDougall and Suen (1997), who found a prevalence rate of 37.6%

in their sample of older adults admitted to three psychiatric hospitals in the United States. This will

be explored further in the following section.

Exploring the difference between this research and other studies.

Blixen, McDougall and Suen’s (1997) work differs from this study in a number of ways,

most notably geographically. Additionally, a higher proportion of dual diagnosis in older adults was

identified, requiring an exploration of the results of the initial phase of this study, which found a

much lower prevalence of 15.5%. There are a number of potential explanations for this discrepancy,

most notably the difference in study methodology and the lack of a formalised screening

instrument. Blixen et al’s work used a retrospective analysis of the entire clinical file, whereas

phase one of this study only examined assessment documents. Moreover, the discrepancy is likely

caused by the haphazard approach to screening identified earlier in this thesis; a lack of a

standardised approach to enquiring about AOD use, the absence of a mandated screening tool and

the propensity for comprehensive AOD assessment to be left to the clinical judgment of interest of

clinicians.

The absence of a comprehensive screening approach is concerning not only in respect of

comparison to the higher prevalence of dual diagnosis found in Blixen et al’s work, but also raises

concerns when considering prevalence rates of co-occurring AOD use and depression in non-mental

health cohorts. For instance, Satre, Sterling, Mackin and Weisner (2011) found 53% of men and

40% of women presenting to a psychiatric outpatient service in San Francisco had alcohol use in the

preceding 30 days. Of those, 35% of men and 35.5% of women attained scores suggesting lifetime

alcohol problems after being administered the SMAST test. In addition, 12% of men and 4% of
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 256

women reported cannabis use with a mean age of onset of 23 years of age, further demonstrating

the importance of screening for AOD use in mental health settings.

Other studies exploring populations of older adults who have undergone comprehensive

screening demonstrate higher rates of AOD use than this study. For instance, Ompad et al (2016)

used the Alcohol Use Disorders Identification Test (AUDIT) in addition to a structured interview to

screen for AOD in 95 individuals aged 50 and over seeking HIV treatment in New York and found

medium risk for alcohol use disorder in 81.1% of participants and high risk in 17.3%. In addition,

23.2% were reported as being drug dependent. Although this is a younger sample than the

consumers presented in this study, it demonstrates that screening markedly changes the reporting of

both problematic and potential substance use disorders in older populations.

These figures are reflected in Chaput, Beaulieu, Paradis and Labonte’s (2011) study of older

adults visiting a psychiatric emergency service department. This study found a 27% prevalence of

AOD use in adults 65 and over in Quebec, Canada. The study had a larger pool of participants

(n=1349 aged 65 and over) but does bear relevance to this project in that it examines a population

of older adults referring to a mental health emergency service, not unlike the referral process

undertaken by MAPS. Again, the higher prevalence found in Chaput et al’s work calls into question

the prevalence found in this study, which has been found to be substantially lower than other

published prevalence rates in similar mental health service providers globally.

Although described as a limitation of the study later in this chapter, the approach chosen to

examine only assessments over the two-year period of time applied to the retrospective file audit

provides opportunity to examine the assessment process itself in terms of AOD screening and

assessment. For instance, best practice in identification of AOD use dictates screening be conducted

as early as possible to enable ongoing treatment planning (Cleary, Sayers, Bramble, Jackson &
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Lopez, 2017; Queensland Health, 2010; Sobell et al., 1988). The results of the first phase of this

study indicate that this was not likely to be occurring, especially when considering the discrepancies

between this study and contemporary research aiming to discern the prevalence of dual diagnosis in

specific populations. Accordingly, repeating the study with the mandated utilisation of an AOD

assessment tool would likely reflect a higher percentage of dual diagnosis. This suggestion for

further research is discussed later in this chapter.

A lack of assessment tool use.

Although no screening tool is a substitute for experienced clinical judgment, the results of

the third phase of this study demonstrate that even experienced clinicians are often hampered when

considering how to raise the issue of AOD use without providing perceived offence. Likewise,

responses to the semi-structured interview process also raised questions around clinicians believing

it was not a core function of older adult mental health services to explore substance use;

accordingly, clinicians described not asking about AOD use with consumers who did not fit their

perceived “profile” of a heavy drinker or substance user or abuser. These findings demonstrate the

need for screening to be uniform in its approach and uniform in its application to all referrals to the

mental health service. This contention is supported by Derry (2000), whose review of both

prevalence and assessment research found atypical presentation and a reluctance to self-report

unless directly questioned common in the older adult population.

Self-report is a common mechanism for assessment in many health services, and despite

best practice suggesting the use of collateral, this may not be available for older adults who have

experienced partner, friends or family losses, or whose dual diagnosis behaviours have resulted in

fragmented family relationships. The validity of self-report has been questioned in the literature

(Del Boca & Darkes, 2003), and throughout the third phase of the study was reported as being

treated as suspect by clinicians. It also raises questions of gender. For instance, it may be possible
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 258

that males are more likely to report their behaviours with alcohol, whereas females may choose to

minimise or avoid reporting at the time of assessment. Lower proportions of females self-reporting

alcohol use as quantity of drinks increased was reported in a large cohort study examining alcohol

use in falls sustained by older adults (Mukamal et al., 2004), and while this may be a trend towards

male dominance of heavy drinking, it raises the possibility that females may in fact under report

their use of alcohol.

There may also be a reluctance to report the use of illicit substances, which remain illegal at

law in the state of Victoria, the setting of this study. Fear of prosecution often remains a challenge

to accurate assessment of illicit substance use and associated activities, particularly in research

settings (Sandberg & Copes, 2013). Alcohol remains legal, socially acceptable and affordable in

Australia, which may make it easier for consumers to disclose their use to healthcare professionals

attempting to provide care. It may also make use appear more overt during home visits, with less

effort required to conceal alcohol as it would not result in prosecution for possession. This

distinction may also go some way to explaining the high prevalence of reported alcohol use in

similar studies.

Several studies have explored the reliability of brief screening instruments, finding high

degrees of specificity and sensitivity (Dawe et al., 2003; Hinkin et al., 2001; Johnson-Greene et al.,

2009). For example, Bradley et al (2007) found the AUDIT-C to be an effective screening tool for

problematic alcohol use among older adults in Veteran’s Affairs clinics in the United States of

America. The AUDIT-C is a three-question screen, addressing the concerns expressed by clinicians

in Phase Three of this study in regards to adding more paperwork to their self-described heavy

workloads. Incorporating the AUDIT-C into the workload of clinicians working with older adults

would enable a brief screen for alcohol use to be incorporated at the point of assessment.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 259

When considering illicit substance use, brief screening becomes somewhat more difficult to

implement. Considering the responses garnered in the third phase of this project where clinicians

reported feeling some hesitancy at asking about lifetime illicit substance use, incorporating

questioning of current illicit substance use may be difficult. Again, this reflects on the presence of

the attitude that older adults are not users of illicit substances (Beynon, 2008). As discussed in the

literature review section of this thesis, this may not necessarily be the case with the ageing of the

baby boomer cohort, who are noted to have different attitudes to illicit substance use and higher

prevalence of usage of illicit drugs.

Addressing this issue may require the use of simple screening cues, as suggested by

clinicians in the third phase of this study. These cues should be simple questions or prompts aimed

at ascertaining the presence of illicit substance use or problematic alcohol consumption, and

positive answers to these questions or prompts should generate a comprehensive assessment for

AOD use using tools that discern not only current use, but lifetime patterns (Sorock et al., 2006). It

would be essential to gather collateral information from family members if possible to corroborate

reported levels of alcohol or illicit substance use as a means to address the potential issues

associated with self-report.

The presence of screening instruments to assess for AOD use would make incorporation of

screening a simple measure for any mental health clinician who was willing to apply them during

an assessment process, however assessing for problematic licit substance use may be somewhat

more difficult. The nature of problematic use of licit substances, for example benzodiazepines or

opiates, would by definition be difficult to detect; these substances are obtained by a number of

methods not limited to purchase on the “black market” as identified by a participant in the second

phase of this study, or through diversion from other sources (for example family or friends) or

through the process of “doctor shopping,” where an individual spends an amount of time visiting
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 260

different clinics or hospitals in order to procure prescriptions for medication (Sansone & Sansone,

2012). Assessing medication charts may not necessarily ascertain problematic use of

benzodiazepines or opiates, requiring sensitive questioning and the development of a screening

instrument to detect the inappropriate use of these medications. Some promise for this type of

instrument was shown in a study by Voyer, Roussel, Berbiche and Preville, (2010), who found high

specificity and sensitivity in a two-question benzodiazepine detection screen in a sample of 707

community dwelling older adults.

Ultimately, screening should be uniformly conducted with all individuals referred to the

service. Extending this philosophy, older adults should be screened at all points of contact with

healthcare providers given that presentations may not necessarily be due to primary AOD use or

mental ill health. Uniform screening would also go some way to address the concerns raised by

clinicians in the third phase of this thesis; when every consumer of mental health services is asked

about the presence of AOD use or inappropriate medication use, this methodology becomes

commonplace and incorporated into day to day assessment tasks. Furthermore, as suggested by

clinicians in the third phase of this study, a decisive culture of screening led by senior clinicians in

the service would go some way to making screening an expected component of every assessment

conducted by the mental health service.

Can clinicians rely on clinical judgment?

Clinical judgment, defined by Tanner (2006) as "An interpretation or conclusion about a

patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or

modify standard approaches, or improvise new ones as deemed appropriate by the patient’s

response", is underpinned by clinical experience and the ability to make assessment decisions based

on decisions or observations made in prior situations similar to the one at hand (p. 204). Clinical

judgement is often mentioned in the nursing literature, frequently as a positive attribute at the core
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 261

of the nursing profession (del Bueno, 2005). In respect of this research project, clinical judgement

was frequently mentioned by clinicians as a means to determine the presence of AOD use. One

participant described observation, for example noticing an extraordinary amount of empty alcohol

bottles or drug paraphernalia present during an assessment in an individual’s home. Further, some

clinicians reported that they felt that observation alone was a skill that would enable them to

determine the presence of problematic alcohol consumption, illicit substance use or inappropriate

medication use.

Mental health nursing literature commonly discusses observation as a process embedded in

minimising risk in inpatient wards (Buchanan-Barker & Barker, 2005; Holyoake, 2013; Rooney,

2009). In fact, it is considered a learned skill and a clinical attribute often present in the most

experienced nurses (Mackay, Paterson, & Cassells, 2005). Personally, I have often joked while

working in inpatient mental health units that the best nurses would casually observe the scene and

be able to describe in great detail where each patient and staff member was when asked at a later

stage. This level of observation is thought to preclude aggression or other issues by recognising

overt signs and providing an opportunity to act in a pre-emptive manner as opposed to reacting

when the crisis occurs, and although is considered the status quo in mental health inpatient settings,

is poorly supported by evidence (Manna, 2010). However, when considering the study at hand, it is

apparent that observation alone may miss AOD use in older adults with dual diagnosis.

Stage one of this research project examined the assessment narrative entered by clinicians

when doing the initial intake assessment of older adults referred to MAPS. During this process, a

number of observations were made. Perhaps the most concerning when discussing clinical

judgement and observation is that of recording that an individual consumes “one or two” glasses of

wine per night, with no quantification of the actual amount being consumed. Revisiting Wilkinson

et al (Wilkinson et al., 2011), who asked older adults to pour alcohol into their standard drinking
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 262

vessel before quantifying the actual amount poured versus an Australian standard drink,

overpouring was found to be common. Accordingly, two glasses of wine may equal six standard

drinks in this context, well beyond the Australian guidelines for healthy alcohol consumption

(National Health and Medical Research Council, 2009).

Further, this raises questions related to clinical judgement when considering what clinicians

may describe as an alcoholic or illicit substance user. Relying on unquantified notions of problem

drinking or describing in terms of “only a couple of glasses” raises the possibility of recording

individuals with problem drinking patterns as negative in the assessment tool. Arguably, the notion

of “sub-threshold” drinking, where frequent consumption of alcohol beyond guidelines yet not

meeting contemporary definitions of alcoholism or alcohol use disorder is one of the most pressing

issues confronting clinicians working with older adults at this time (Wilson, Knowles, Huang, &

Fink, 2014). This type of drinking is noted to be frequently injurious to health and a common

comorbidity of depressed mental states (Fink et al., 2002).

Addressing this issue would require a concerted effort to determine the actual amount of

alcohol consumed by asking an individual to demonstrate a usual pour into their usual drinking

vessel, as per the methodology employed by Wilkinson et al (2011), or to ask the consumer to

measure their drinks over a period of time and record them in a diary as is common practice in

AOD treatment settings (Wallace, Cutler, & Haines, 1988). When considering illicit substances, it

becomes somewhat more difficult to determine exact quantities due to differences in terminology

and weights between substances. Using observation to recognise the presence of illicit substance

use is a good start, however it then becomes imperative to discuss frequency and quantity in order

to formulate a treatment plan that is relevant and appropriate to the individual in question.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 263

Arguably, the greatest application of clinical judgement is in the initial screening process

itself. Screening tools allow a rapid dissemination of questions designed to ascertain the presence

and severity of AOD use, yet many clinicians are able to ask these questions without physically

holding a sheet of paper in front of them during assessment. Placing most focus on a piece of paper

contravenes good assessment practices, including active listening, eye contact and actually being

present for the consumer during their time of need (Beck, Daughtridge, & Sloane, 2002). A

clinician echoed this sentiment during phase three of this study, lamenting that a perceived burden

of paperwork made him feel like a “clipboard clinician.” Although this is a valid concern, perhaps

the greatest utility in screening tool application would be to provide a degree of capability to novice

clinicians, who are often expected to complete comprehensive assessments while relatively

inexperienced. The use of structured screening tools or prompts in this instance may ensure that

every individual assessed is asked about their AOD use.

Not only does good clinical judgement allow screening to occur in a more organic process

than simply reading verbatim from a screening tool, but it also opens the door to ongoing discourse

surrounding AOD use during future interactions with consumers of mental health services. This

allows a number of positive interventions, including harm reduction and ongoing assessment of the

readiness to make changes to substance use. This is especially important given that research reports

that many people who use AOD often make positive moves to change or cease their use when

offered these opportunities during clinical interactions (Ogle & Baer, 2003). Unfortunately, reading

screening tools verbatim is a key component of their reliability and therefore may effect the

specificity and sensitivity reported by each tool (Humeniuk et al., 2008; WHO ASSIST Working

Group, 2002).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 264

Complexity.

Complexity is a high driver of healthcare expenditure, with multiple chronic conditions

being recognised as a substantive financial burden on healthcare providers (Mapel, Dutro, Marton,

Woodruff, & Make, 2011; Wolff, Starfield, & Anderson, 2002). In addition, complexity is

recognised as being difficult to manage, often with many services performing many different roles

for the consumer; at times, this care is often not coordinated, leaving the consumer in the midst of

many services who often do not communicate well if at all (Chumbler et al., 2005).

In spite of the results of phase one of this study, which present the older adults with dual

diagnosis as a largely homogenous group of predominantly male, depressed consumers of alcohol,

this was not reflected in the second phase of the study which described a small cohort of individuals

with dual diagnosis; diverse substances, different illness trajectory and mental health diagnoses.

This finding is curious, as studies examining older adults with dual diagnosis often demonstrate

similar findings of comorbid depression and alcohol abuse (Blixen et al., 1997; Coulson et al.,

2014). This will be discussed further in the following section.

A poorly understood population.

The participants in the second phase of this study, although mostly male, tend to

differentiate from this homogenous model, being distinctly different in respect of the substances

they choose to use, their mental illness history and medical and psychosocial complexity. Although

a small pool of participants, this group raises questions of the idea that older adults with dual

diagnosis prefer alcohol, and also hints at the complexities inherent in skilful clinical assessment.

The historical synopses outlined in Chapter Six illustrate the lifelong complexity involved in dual

diagnosis, and older adults are no different. In fact, as illustrated in the second qualitative phase,

these complexities are often carried throughout life and become more pressing during older age

where it is likely that a higher number of medical presentations and age related issues associated
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 265

with AOD use, such as falls and cognitive impairment, may compound underlying issues and make

holistic care very difficult to apply.

Despite these issues, older adults with dual diagnosis remain a poorly understood population

due primarily to the distinct lack of research into this cohort. This may be due to the nature of

presentations, as has been discussed earlier in this thesis; many older adults with dual diagnosis

may be isolated and only present secondary to physical comorbidity or injury. Accordingly, it

appears difficult to provide a comprehensive account of the needs of older adults with dual

diagnosis as a cohesive group when there are a multitude of variables that affect each and every

individual fitting this broad diagnostic umbrella. Although this is not limited to older adults with

dual diagnosis, it is apparent that they often have substantially differing needs to their younger

counterparts, as discussed in Chapter Three of this thesis.

Also impacting on the understanding of this population is the belief held in some camps that

older adults simply do not use illicit substances. This is complicated to an extent by some clinicians

who believe that “taking” away “one last vice” is inappropriate and detrimental to rapport in the

mental health setting. This was evident to an extent in the third phase of this study, with clinician

participants reporting that it should not be the task of a mental health service to discuss or address

problematic alcohol or substance use. Unfortunately, this opinion appears to have crept into

research funding arenas, with a cursory search of the literature finding few published studies of

substance on older adults with dual diagnosis.

Further, when discussing the literature, it appears that a significant limitation is that of

cohorts. For instance, older veterans, the homeless, injecting drug users, those who binge drink in

retirement communities, inappropriate benzodiazepine users, isolated older adults with alcohol use

disorders and “late adopters” of AOD who commence use after late life losses are all quite diverse
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 266

populations, with different needs and levels of complexity. Drawing together a comprehensive

strategy to undertake research into the needs of these individuals would be a large task, and one

requiring heavy funding and support from Government bodies. This goes someway to explain the

dearth of research into this area, however the absence of quality data makes moving from

describing the older adult with dual diagnosis to investigating treatment difficult, if not impossible.

Complicating these issues is that of presentation. As mentioned repeatedly in this thesis, this

research project examines a single setting whereas older adults may present to a wide variety of

settings where they may receive screening and treatment for their comorbid mental ill health and

substance use disorder, or they may receive none. Withdrawal management, particularly concerning

alcohol, is a key focus of many healthcare settings however there are still instances where not

asking about alcohol or drug use may lead to unmanaged withdrawal, a potentially fatal situation

(McKeon, Frye, & Delanty, 2008). Likewise, the pressure for throughput in modern healthcare

systems means referral for issues that are not central to the key complaint may not be completed

due to fears that the patient’s stay will become longer and block access for others needing hospital

care (Chou & Chen, 2010).

It is clear that there are a number of cohorts and settings that concern older adults with dual

diagnosis, and research interest has not kept pace leading to a poorly understood population. Further

research recommendations are listed later in this chapter and are based on the research gaps

identified throughout the course of this research project.

Perceptive simplicity of the term “dual diagnosis.”

Weiss, Mirin and Frances (1992) lament the term dual diagnosis as being “… used in a way

that implies homogeneity in this group of patients, as if such an identification will facilitate

treatment planning. On the contrary, the typical dual diagnosis patient is a mythical creature,” (p.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 267

107). Herein lies the perceptive simplicity of the term dual diagnosis, whereas the reality is often

fraught with a large number of interrelated issues as demonstrated in the participant backgrounds

outlined in the second phase of this study. By its very definition, dual diagnosis describes two

disorders. These disorders have historically been understood to be mental ill health and substance

use disorder. However, in the older population there are often significant comorbidities present with

dual diagnosis, including poor physical health, psychosocial factors and multiple medical

conditions. These factors are also evident in the histories of the participants presented in Chapter

Six. By labelling older adults as having dual diagnoses we also relate them to their younger

counterparts, who also carry a high degree of complexity but lack many of the issues specific to the

older cohort. Echoing Weiss et al (1992), it is a deceptively simple term which does not do justice

to the myriad of problems accompanying the core features of mental ill health and substance use

disorder.

Additionally, clinicians often express a reluctance to work with individuals who have been

labelled with dual diagnosis. Frustration is evident, as is the notion of clinical helplessness

discussed in the third phase of this study. This frustration has been shown in the work of Deans and

Soar (2005), whose phenomenological study of clinicians working with individuals with dual

diagnosis described high levels of stress when managing this cohort. Rather than being seen as

“core business,” (Victorian Government Department of Human Services, 2007), dual diagnosis

instead becomes the diagnostic classification that arguably no clinician wants on their caseload.

Revisiting the second phase of this thesis demonstrates the differences between six

individuals who have all been diagnostically labelled with dual diagnosis. All of the participants in

this phase have diverse mental illness and AOD use trajectories. All have diverse medical

conditions. Some have forensic histories, and diverse psychosocial situations. The previous section

described complexity as a term, however these participants demonstrate true complexity. Although
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 268

they are all technically dual diagnosis, no uniform treatment plan exists, and perhaps this goes some

way to describe the uncertainty that clinicians feel when providing case management, inpatient

treatment or any other form of support to this cohort.

Given the wide spectrum of AOD use and mental ill health in older adults with dual

diagnosis, it may be prudent to revisit the nomenclature used to describe this population. Many

older adults present with some degree of comorbidity between mental health and AOD use, and to

describe them as dual diagnosis consumers seems to imply what their younger counterparts have

experienced for some time: that dual diagnosis is usually reserved as a label for those with the most

severe mental ill health and substance use disorder. Although both may exist in the older adult, they

are often accompanied by a number of interrelated factors that impact on the overall health and

social wellbeing of the individual, especially when considering ageing as a construct unique to the

older adult cohort.

Siloed care.

Contemporary discourse surrounding healthcare services often speaks of siloes. In respect of

healthcare, siloes are considered to be both invisible barrier and container; invisible barrier in

fragmenting parts of an organisation, and container of like-minded individuals operating within the

aforementioned barrier (Cilliers & Greyvenstein, 2012). Siloes have been shown in research to

disrupt the continuity of care individuals receive during healthcare encounters (Mann, 2005). In

addition, siloed care frequently results in a lack of coordinated care between services; as mentioned

earlier, when considering complexity, it is not unusual for individuals to be receiving care from a

number of medical or health teams. Considering provision of care as compartmentalised, for

example one service providing only mental health care, frequently results in a stream of referrals

and “handing over” of consumers with no real endpoint. Unfortunately, according to Kilbourne,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 269

Fullerton, Dausey, Pincus and Hermann (2010), this style of care seems to be prevalent in modern

healthcare, especially where co-occurring disorders are concerned.

Siloed care is evident when examining the histories and discourse in the second phase of this

thesis. It is also inherent when considering the responses of clinicians to the semi-structured

interview process conducted during the third phase of this research project, whereby addiction was

seen to be a sub-speciality to mental health. In reality, both mental illness and substance use

disorders are closely intertwined processes, as evidenced by the success of integrated treatment

programs that aim to address both of these issues concurrently (Granholm, Anthenelli, Monteiro,

Sevcik, & Stoler, 2003). Separation of responsibilities for care, for example describing mental

illness as “our” treatment domain and either neglecting or attempting to “refer out” care for

addictive behaviours is neither a cohesive clinical approach nor is it evidence based best practice in

caring for individuals with dual diagnosis.

The true danger of siloed care is the propensity for individuals to fall into gaps between

services, as described by McDermott and Pyett (1993) and discussed extensively in Chapter Three

of this thesis. In this case, individuals may not be accepted by mental health services due to a belief

that the problem is “not acute” enough for the service in question or an idea that the issue was

solely related to addiction, and therefore not suitable for the service; certainly, this issue was

described by clinicians in phase three of this research project where it was stated that referrals

would likely be refused if the sole problem was considered to be related to alcohol or other drugs.

Conversely, individuals may not be accepted to AOD treatment services if their mental health or

medical needs are considered too acute to be managed by the service, an issue that is prevalent in

the older adult population (Johnson, Brems, & Burke, 2002; Speer, O'Sullivan, & Schonfeld, 1991).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 270

It can be argued that due to the nature of siloed care, contemporary mental health and AOD

treatment services are not addressing the complexity inherent in older adults with dual diagnosis.

For example, siloed care may result in poor connection with medical services who may be

providing care to individuals with dual diagnosis. Likewise, a focus on treating mental ill health

may neglect the psychosocial or medical issues apparent in an individual’s current situation. Older

adult mental health services such as MAPS, who operate on an outreach model are better placed

than services who work on a clinic model as they have the opportunity to truly assess an individual

holistically, assessing their living situation and function outside of a hospital or community-based

clinic. Unfortunately, Victoria is home to only one older adult specific AOD treatment service that

operates on an outreach model: The Older Wiser Lifestyles (OWL) program, which was described

in Chapter Two of this thesis. Requiring individuals with high levels of complexity to attend clinics

is fraught with the danger of them not attending and therefore being discharged from a service with

their needs failing to be met (Raynes & Warren, 1971).

Finally, siloed care exists within clinicians themselves. As evidenced in the third phase of

this thesis, clinicians did not consider themselves adept at managing dual diagnosis presentations. A

variety of reasons were given for this, including a perceived lack of knowledge or skill. A

recommendation presented in the next chapter of this thesis is to develop specialist positions for

dual diagnosis in older adult mental health services, however this can result in clinicians detaching

themselves from the provision of dual diagnosis care, instead delegating it to this specialty position.

This phenomenon has been documented by Myors, Cleary, Johnson and Schmied (2015), who

found that in spite of specialty perinatal and infant mental health clinicians believing they were

operating in a collaborative manner, collaboration was described as being hard work with little

actual collaborative work substantiated in the research. Addressing this issue will be discussed

further in Chapter Nine, however it demonstrates the difficulties in implementing truly integrated

dual diagnosis care in contemporary mental health services. It also demonstrates the change from
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 271

earlier mental health services, with clinicians describing them as taking all presentations and

providing care for addictive behaviours, as discussed in Chapter Two of this thesis.

Siloed care remains a significant challenge to contemporary healthcare services and may be

an inevitable result of the drive to specialisation, particularly in the nursing profession. Nurses are

frequently driven to specialise in ever narrowing fields of nursing care. Perhaps the best

demonstration of the issues arising as a result of this approach is the growing body of work

concerning physical health in individuals undergoing mental health care. This has long been

recognised as a neglected area of treatment in mental health, particularly with the poor physical

health and high rates of cardiometabolic disease in this population (Galletly et al., 2012). The

recognition of shortened life spans and high mortality associated with these factors has led to the

creation of many innovative programs addressing poor physical health among many consumers of

mental health services (Druss et al., 2010; Shiner, Whitley, Van Citters, Pratt, & Bartels, 2008). It

seems that a similar push for integrated dual diagnosis care is imminent and should be included as

part of a holistic approach to patient care in mental health services.

Workforce readiness.

As described in the third phase of this thesis, many clinician participants felt that a lack of

educational preparation hampered their ability to provide comprehensive care to older adults with

dual diagnosis. In addition, a number of other factors were described that indicated a poor

workforce readiness to address dual diagnosis in older adults, including a lack of collaboration with

other service providers and a belief that training seemed to be an exercise designed to “tick boxes”

rather than provide practical, useful strategies in working with older adults with dual diagnosis.

These issues will be discussed in the following section.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 272

Educational preparation.

As described in the opening paragraph of this section, clinicians participating in phase three

of this research project described a lack of educational preparation in caring for individuals with

dual diagnosis. While this is not a new finding, having been described by other researchers in the

field of addiction (Deans & Soar, 2005), it is concerning in a participant group with a diverse range

of experiences. Leino-Kilpi, Solante and Katajitso found that educational preparation regarding

AOD use was lacking in graduate nurses in Finland (2001), who reported low preparation and

education in caring for this cohort, and likewise deCrespigny (1996) who described poor knowledge

in alcohol consumption guidelines and assessing AOD use in registered nurses.

During the semi-structured interview process, clinicians expressed a desire for further

education in the use of assessment tools and asking around AOD use in general. A prevailing theme

was the need for education to be practical, rather than providing copious amounts of theory. Many

of the participants described the need for educational preparation to be able to be delivered and

taken to real world situations immediately, a desire for strategies to manage dual diagnosis with the

consumer. Again, this is echoed by the work of Deans and Soar (2005), whereby their participants

described a high level of skill and knowledge required to work effectively with individuals with

dual diagnosis.

Further, participants in the third phase of this study went on to describe the power of sharing

information on how they managed older adults with dual diagnosis as a means to further their

learning. While many scholars have advocated for sharing of clinical experiences as a means to

enhance learning and clinical judgement (Murphy & Timmins, 2009; Tjoflåt, Razaonandrianina,

Karlsen, & Hansen, 2017), the modality for MAPS was to describe consumers in a case review

format that one participant felt was too focussed on the problem and the longitudinal progression of

their episode of care. This participant then went on to describe a need for these discussions to
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 273

involve more of how particular problems were addressed, again reflecting the desire for education

and knowledge sharing to be practical and applicable to everyday clinical work.

Some went further to describe the desire for greater recognition of AOD within the MAPS

service, for example setting an expectation for every consumer or individual assessed that AOD use

would be asked and discussed accordingly. One participant described this in accordance with the

administration of the Mini Mental State Examination (MMSE), which was expected to be

administered with every individual assessed by MAPS. Also expressed was the belief that having

clinicians with AOD experience or interest would make conversations around AOD use during

clinical reviews the status quo, as opposed to these discussions being incidental to the finding that

AOD use was present.

Despite this research project investigating experienced clinicians, the nature of education

provided in pre-registration undergraduate settings needs to be considered when discussing

educational preparedness. As mentioned earlier, the lack of education around addictive behaviours

in undergraduate health programs is concerning (Rassool, 2007). However, given the nature of

older adults with dual diagnosis to present in settings other than mental health and AOD treatment,

it is imperative that future clinicians are provided with at least a fundamental grounding in the

prevalence of dual diagnosis, assessment strategies and the critical importance of referral for

specialist input and treatment. It must be pondered that a future workforce possessing this

knowledge and skill would negate the need for an exploratory study such as this, providing

neophyte clinicians with the skills and knowledge to assess for AOD use in older adults, an issue

becoming more important with the ageing baby boomer generation and the issue of sub-threshold

alcohol consumption, both of which are described earlier in this chapter.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 274

The issue of a lack of educational preparation in mental health settings raises concerns that

nurses and other health professionals in other, more generalist settings are simply not assessing for

AOD use or identifying the need to do so. Again, this reflects on observation: when AOD use is

overt, it is easy to detect and manage. However, it is not often overt in the older adult population,

requiring uniform assessment to be conducted with every encounter of older adults with healthcare

providers. With health professionals in generalist or primary care settings, conducting AOD

assessment may not be a priority or be considered at odds with the goal of treating acute medical

issues. Perhaps with greater knowledge of the issues associated with dual diagnosis in older adults,

nurses would be able to detect these issues prior to them escalating to the point where individuals

become high consumers of healthcare resources. This will be discussed further as a

recommendation in the next chapter of this thesis.

The utility of training.

Following on from the previous section is a discussion of the actual utility of training

provided to clinicians caring for older adults with dual diagnosis. While a lack of educational

preparation was identified, participants in the third phase of this research project identified

attending training aimed at rectifying knowledge and skills gaps in the provision of care to older

adults with dual diagnosis. For example, one clinician described attending a training session that

was geared towards older adults with substance use disorders, however found that this did not

provide practical skills relating to assessment or management of AOD use in this cohort. Echoing

the discussion provided in the previous section relating to educational preparation, the desire for

practical, immediately applicable training was described by a number of responses from clinicians

in the third phase of this project.

As it stands, education sessions, in-service training and short course formats are the

mainstay of training and skills provision in the healthcare workforce. Although there is much
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 275

literature discussing the efficacy of this method of knowledge dissemination (Forsetlund et al.,

2009), there is a widely varying nature and quality of these educational approaches that needs to be

considered. These training sessions are often provided “in house” by the health service itself or may

employ external providers.

One participant in the third phase of this thesis described a feeling that while useful, training

sessions were an adjunct to actual clinical experience and expertise. Others spoke of learning from

more experienced colleagues or discussing the approach to dual diagnosis cases in an informal

setting, as explored in the previous section. While a wide variety of suggestions were discussed

during the semi-structured interview process, it is apparent that the contemporary training being

delivered was felt to be inappropriate for MAPS, and therefore this calls into question the training

provided to mental health clinicians working with older adults statewide.

Again, clinician participants clearly stated their requirements for practical education;

assessment and asking questions around AOD use, alcohol guidelines and quantifying AOD use.

They also asked for strategies to assess readiness for change. Although the use of specialist

clinicians’ role modelling competent AOD practice was suggested by many, it is clear that this role

would be required to continually provide training and support to clinicians working with older

adults with dual diagnosis.

In spite of the desire to have a clinician with a dual diagnosis focus on the multidisciplinary

team, participants in the third phase recognised that training could be meaningless without ongoing

exposure to individuals with dual diagnosis. This is a recognition that training should be an adjunct

to clinical practice rather than a prescriptive formula applied to every situation, mirroring the work

of Weiss et al described in the beginning of the complexity section of this chapter (1992). Again,

this demonstrates the utility of a specialist AOD role to mentor and provide support to clinicians
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 276

working with consumers with dual diagnosis, and likely high degrees of complexity.

Recommendations for changes to training methodologies are outlined further in the next chapter of

this thesis.

A lack of intersectorial collaboration.

Also identified in the third phase of this thesis was a distinct lack of intersectorial

collaboration. As demonstrated in the semi-structured interview process with clinicians,

understanding of where to refer consumers with dual diagnosis and the need to discuss this referral

from the initial point of care was poor. Clinicians reported relying on conversations with other

clinicians or simply not making AOD referrals due to a belief that the behaviour was longstanding

and resistant to change. As research indicates, integrated treatment of mental health and addictive

behaviour in addition to early treatment planning is current best practice in any dual diagnosis

cohort, these responses indicate that MAPS was not operating within the current evidence based

guideline for care of this cohort (McGovern, Lambert-Harris, Gotham, Claus & Xie, 2014; Drake,

Mueser, Brunette, & McHugo, 2004; Barrowclough et al., 2001; Drake, Mercer-McFadden,

Mueser, McHugo, & Bond, 1998).

The poor understanding of the referral process to AOD treatment services may be somewhat

explained by the recent restructure of the AOD treatment sector in Victoria. Widely criticised, this

restructure aimed to “centralise” services within geographic catchment areas, much like the

structure publically funded mental health services currently operate under (Department of Health,

2013d). A core aim of this process was to reduce access blockages by reducing “gatekeepers,”

however clinicians and consumers alike report that this is not the case. A report by Berends and

Ritter showed that access was more difficult, with clinicians in this study reporting finding

understanding the referral process difficult (2014). The report also found that many clinicians were

told to have consumers call services directly to complete the referral process, leading to a procedure
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 277

whereby individuals expressing an interest in engaging in AOD treatment were simply handed a

card and advised to call the service themselves. At the time of writing, a draft proposal to alter this

process is being considered by the Victorian Government Department of Health, allowing clinicians

to make direct referrals for AOD treatment.

A consequence of this system is that consumers often begrudge having to undergo many

assessments, often describing repeating their history and concerns as a burden and barrier to

contacting services. Certainly, once a mental health clinician conducts a comprehensive assessment

often with a secondary assessment conducted by either a psychiatrist or psychiatric registrar, one

can only wonder whether this cumbersome system is actually necessary in order to commence

treatment. Likewise, the state of change of AOD treatment services in Victoria has led to confusion

within the clinicians interviewed for the third phase of this thesis; some described old services and

assessment processes that predates the service reform in Victoria as opposed to the newer process.

A suggestion made by one of the participants was that representatives from AOD services

maintain open dialogue with MAPS, visiting and conversing with clinicians to explain the

assessment and treatment process for their service. Likewise, it was felt that this arrangement would

also work with mental health services visiting AOD treatment services, and although this research

project is based at a mental health service alone, issues with managing mental health in AOD

treatment have been reported frequently in the literature (McGovern, Lambert-harris, Gotham,

Claus, & Xie, 2014). This idea somewhat reflects the concept of reciprocal rotations between

services as discussed in Chapter Two of this thesis, which although was found to be somewhat of a

failure when attempts were made to implement it, had proven to be beneficial for my own practice

as described in Chapter Two.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 278

Navigating both systems of care may be made easier by the advent of recovery coaching. A

concept described by LePage and Garcia-Rea (LePage & Garcia-Rea, 2012) in the United States of

America, this system uses a clinician to advocate and converse with various services an individual

is involved with, providing one key point of contact for the individual in question and an

experienced clinician to liaise with services directly. Coaching may also encompass a number of

holistic and lifestyle domains to prevent relapse, as described in other models. Early indications in

other healthcare domains indicate that this methodology is successful in actually getting individuals

involved in treatment and keeping them engaged (Lashley, 2007). Notwithstanding, this is a model

that could be employed within MAPS, allowing a secondary goal of building collaborate

relationships with AOD treatment providers and other healthcare networks to enable smooth

transition of individuals into differing services.

System response.

The systematic response to dual diagnosis in older adults is critical to evaluate for a number

of reasons; the growing body of research suggesting an ageing baby boomer cohort with a higher

degree of AOD use, the nature of an ageing population and the costs associated with providing care

to a growing number of older adults with complex health needs in the future. Combined, these

factors indicate a potential increase in the number of older adults with dual diagnosis requiring care

by both mental health services and AOD treatment services, with growing costs indicating the

possibility of services having to provide care to a greater number of individuals with less resources.

This section will discuss issues associated with the current system response to older adults with dual

diagnosis.
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"Not our business."

McDermott and Pyett’s (1993) report identified the notion that individuals with dual

diagnosis were “not welcome anywhere,” due to both mental health services and AOD treatment

services believing them to be inappropriate to their service. This report suggested a “no wrong

door” policy, whereby all referrals would be accepted and either provided care or assisted to attain

care from a service that suited their needs. Further, the Victorian Government’s Key Directions

(2007) document called for services to treat dual diagnosis as “core business,” suggesting a raft of

measures to ensure individuals received appropriate, timely care for co-occurring mental ill health

and AOD use disorders. These documents should ensure that this section of discussion ends here,

however it is apparent that neither “no wrong door” or dual diagnosis being “core business” is

applicable to the results garnered from all three phases of this research project.

As described by clinicians who frequently took initial referrals as requests for MAPS care,

discussing individuals who were considered to have issues related to AOD use alone were often not

taken for further assessment and treatment. Examples of this are provided in Chapter Seven,

whereby a clinician participant identifies the reluctance to assume care for an individual with

behavioural issues secondary to methamphetamine use. Likewise, other participants discussed a

high degree of pressure to discharge consumers who were felt to be “stuck,” or making no progress

with their AOD use and likewise their mental state. As shown in the first phase of this research

project, the likelihood that these individuals would be discharged from the care of MAPS with no

ongoing AOD treatment was high.

This issue is not necessarily unique to MAPS, with reports in the literature showing that care

for AOD use disorders is frequently lacking or absent in mental health treatment settings

(McGovern et al., 2014). This issue was identified as a key component in many mental health unit

inpatient deaths examined in the Chief Psychiatrist’s report (Department of Health, 2012),
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 280

describing absconding from mental health units and overdosing as causes of death in a number of

cases. These findings in themselves point to a lack of comprehensive AOD treatment, particularly

in the withdrawal stage, and led to a provision of the Mental Health Act (Parliament of Victoria,

2014) dictating that all individuals receiving mental health care have their AOD use addressed.

Despite all of this evidence and recommendation for integration of dual diagnosis care into

mental health service delivery, the discourse provided by clinicians shows that this is not the case.

Further, it appears that “top down” leadership in both advocating for adequate care provision and

treating dual diagnosis as “core business” was lacking according to responses from clinician

participants. In fact, the pressure to discharge consumers described by the participants appears to

point to a reluctance to maintain care for this cohort; participants reported feeling that even small

gains in consumers with dual diagnosis were felt to be trivial, and also that there was a need to

continually advocate to provide ongoing care to the dual diagnosis cohort.

As described in the first phase of this research project, although a prevalence of 15.5% may

appear to be small, this number accounts for 92 individuals with complex needs and a high need for

clinical input whilst part of the caseload of the mental health service. Likewise, this prevalence may

indeed be higher due to the lack of a cohesive screening approach when compared to the results of

other similar studies discussed earlier in this section. Therefore, failing to provide care for

individuals with dual diagnosis, or attempting to keep consumers engaged in the service appears to

be a failure to provide care for some of the most complex consumers the mental health service is

likely to encounter.

The need for leadership in caring for individuals with dual diagnosis will be discussed in the

recommendations outlined in the next chapter of this thesis, however it should not be understated

that a clear service vision is required. As one of the clinician participants stated, dual diagnosis
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 281

must be made a service priority in order to become adept at caring for individuals with co-occurring

mental ill health and AOD use disorders. It is apparent that this is an essential prerequisite to meet

the potential high demand for care for this cohort that is likely to follow a changing demographic

profile.

A rigid service delivery model.

Given the demonstrated high degree of comorbid mental ill health among older adults with

substance use disorders (Urbanoski, Kenaszchuk, Veldhuizen, & Rush, 2015) the lower prevalence

of dual diagnosis raises the question of whether older adults with substance use disorders present to

mental health services. For instance, this cohort may not come to the attention of community mental

health providers or crisis services due to the nature of their addiction, which as discussed in Chapter

Three, tends to contrast with the younger dual diagnosis consumer who is typified by

methamphetamine and other stimulant use and chaotic mental health presentations (Chaput et al.,

2011; Moos et al., 1995). As discussed earlier in this thesis, the likelihood of incidental finding of

dual diagnosis in general medical settings is high. Accordingly, this raises the question of whether

the current older adult mental health system is actually appropriate to older adults with dual

diagnosis.

As a service, MAPS operates on arguably a rigid service delivery model. Referrals are taken

by facsimile or telephone, screened by a referral clinician and presented at a team meeting where

they are vetted before progressing to a formalised assessment with a mental health service clinician.

Accordingly, the service relies on self-report as a form of referral, or referral by health professionals

or family, friends or significant others. Arguably, this rigid service delivery model fails in meeting

the consumer where they need service, for example at the location of their presentation. This may

be community health clinics, general practise and primary care or general hospital settings.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 282

The service delivery model of MAPS is based on the way adult (aged under 65) community

mental health services operate, with some minor differences incorporated to provide more enhanced

care to age-specific needs, including a model of outreach where the consumer is met in the

community (Loi & Hassett, 2011). Although this modification goes some way to address the issues

associated with this model of service delivery, it is clear that there needs to be a comprehensive

examination of the applicability of the older adult community mental health model now and into the

future. Meeting the individual where they present, rather than relying on an antiquated system of

referral and response may indeed be a prerequisite to meeting demand; likewise, providing rapid

assessment and treatment planning without the need to plead a case for assuming care of an

individual should be facilitated as opposed to rejecting referrals based on a telephone screen.

Likewise, clinicians participating in the third phase of the study described a sense of

isolation when providing care to older adults with dual diagnosis, describing a desire for a

collaborative team approach within a case management model. Historically, MAPS has operated

along the caseload model: a clinician is allocated a certain number of “cases,” and required to

provide care for those on his or her caseload alone. Moving to a team-based model of case

management has a number of advantages, not least allowing a continuity of cover given clinicians

may work varying days, a better ability for crisis management given most of the team will have

worked with an individual and have some form of rapport and an ability to truly work in a

collaborative, multidisciplinary team. This moves from the “generic” role identified by one

clinician and allows team members to maintain and participate in line with their discipline. Day et

al (2012) found acceptance by clients and reduced wait times associated with case management

access in a study of the team-based approach amongst opiate treatment program recipients in New

South Wales.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 283

A rigid service delivery model also fails to recognise the concept of adaptive substance use

in older adults, both comprehensively examined by Levy and Anderson (2005) and shown in the

second phase of this thesis. Additionally, the notion of fluidity, where individuals move in and out

of AOD use over time, between substances and with various periods of abstinence, does not

necessarily accord with the traditional community based mental health service delivery model.

While beyond the scope of this thesis, the model underpinning contemporary community

mental health service delivery in respect to older adults requires examination and a potential rethink

in order to meet the criteria of meeting the consumer where they present. This would require the

creation and cultivation of professional partnerships with other service providers, both within the

health service itself and other community and healthcare organisations. Accordingly, examining the

model of a sole case manager providing care to an individual “on their books” may indeed assist in

true integration of multidisciplinary roles, with the outcome being better provision of care for older

adults with dual diagnosis.

Setting.

Throughout this discussion, the notion of setting has been mentioned frequently. In respect

of older adults with dual diagnosis, setting refers to where individuals present, are assessed and case

managed. The contemporary literature abounds with reports of older adults with dual diagnosis

presenting in various settings (Bartels et al., 2005; Carter & Reymann, 2014; Speer et al., 1991).

Settings are many and varied, and in the vein of the previous section, not necessarily in accordance

with where contemporary older adult mental health services would operate.

There are some linkages between various mental health disciplines where older adults with

dual diagnosis are identified and referred back to the mental health service itself, the most notable

being a consultation-liaison psychiatry service (Devasagayam & Clarke, 2008). Under this model,
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 284

clinicians assess individuals referred to their service by a home medical team, with these individuals

usually being inpatients of some form, admitted to an inpatient hospital ward. However, this method

again relies on referral, with the traditional form of vetting administered when referrals are

presented to the multidisciplinary team. Also, community mental health clinicians, due to referral

timing and potential lack of links with the home medical team may be in no position to influence

the care of the consumer nor the discharge planning process, both of which are fundamental to

ensuring comprehensive care in individuals with complex medical needs (Southern, Berger, Bellin,

Hailpern, & Arnsten, 2007).

Although painted as a negative in respect to MAPS, the community outreach setting does

offer some substantial advantages to a mental health service that is willing to embrace the concept

of taking the provision of their service to the consumer, rather than waiting for the consumer to be

referred to them. Flexible delivery also allows the implementation of ideas such as novel screening

approaches, whereby generalist clinicians employ short screening instruments with a supported

linkage to a mental health service for more comprehensive screening and treatment planning

(Edlund et al., 2004).

In addition to these benefits, meeting the consumer where they present also allays staff

anxiety around providing care to mental health consumers on medical wards. Research shows that

inpatients in generalist hospital settings with mental ill health often experience stigma and negative

attitudes (Ross & Goldner, 2009). Accordingly, allowing a mental health clinician to advocate for

the consumer and provide input into the treatment and management process may allow staff to feel

supported, as documented by Chikaodiri who described a tendency for healthcare workers to

express fear regarding the treatment of psychiatric inpatients in a general hospital environment

(2009). Additionally, it is also likely to help the consumer achieve optimum outcomes in respect of

their medical treatment and ongoing care.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 285

The setting of older adult mental health services requires further research, as discussed in

the next chapter of this thesis. However, it does indicate some benefits when compared to a

traditional case management model, the most notable of which is a reduction of resource

consumption in an intensive model. Additionally, it allows for brief intervention, which has been

shown to reduce healthcare consumption (Ballesteros, Duffy, Querejeta, Ariño, & González-Pinto,

2004). Further, it allows community mental health clinicians to become a key component of a

multidisciplinary team, providing input into management of an individual’s complex conditions

while an inpatient of a general hospital ward, and to provide expertise in respect of discharge

planning and ongoing community care.

Limitations of the Research

There are a number of limitations inherent in the design of this study that must be

considered when interpreting the results. The primary limitation is the service-based nature of the

project. It was conducted within one health service in Melbourne, Australia, which operates within

a finite geographical catchment area. Accordingly, and although this is not the intent of this study, it

cannot be generalised to other mental health populations both nationally and internationally. Having

said this, MAPS is a major Australian older adult mental health service, providing services to a

large population in Victoria.

The first phase of the project is limited in that only assessments were viewed and included

in the statistical analysis, meaning individuals who disclosed their AOD use after the initial

assessment were recorded as a negative. This may also go some way to explaining the results of this

study when compared to those of Blixen (1997), who found a much higher rate of dual diagnosis by

conducting an audit of the entire clinical stay. As discussed comprehensively in this section, the

lack of a uniform screening tool may also have influenced the results, requiring a revisit of the

process with a mandated screening tool to ensure relative accuracy.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 286

Further, the first phase is also limited by the data collection methodology itself. Research

indicates that clinical notes may not entirely be accurate, with omissions common (Cradock,

Young, & Sullivan, 2001). This may be due to time constraints placed on the individual clinician, or

in the recording process or system itself. As such, it was only possible to examine the data

presented. Missing data is assumed to be not collected, however it remains a possibility that it was

collected and not recorded.

The second phase of the study is limited by the small numbers, which were largely a product

of the difficulty of recruitment. These difficulties are elaborated further in Chapter Four.

Additionally, only one female volunteered to participate in this phase, leading to an imbalance of

genders. Other potential female participants approached to participate declined. This phase is also

cross sectional, in that it captures the experiences of the participants at a set point in time as

opposed to a longitudinal approach which would provide for follow up interviews after the initial

contact. Again, this is discussed in the suggestions for further research section of this chapter.

As discussed in the ethical issues section of Chapter Four, interviewing families and other

service providers would enable a more comprehensive picture of the histories of each participant in

the second phase of the study to be presented. Advice from the health service ethics committee was

sought in regard to this process, and it was felt that the nature of seeking consent from both the

participant and all family members would be difficult and limiting in nature. Hence, although each

participant provided a candid account of their histories in respect to mental illness, AOD use and

the care provided to them, it could not be corroborated with their family or other care providers.

Likewise, returning to complete a second, or potentially third interview was initially

considered during the conception of the methodology for the second phase of the study.

Unfortunately, all six participants stated that they would only like to complete one interview after
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 287

being explained the method on the plain language statement. Completing subsequent interviews

would allow for the transcript to be analysed and further questions to be formulated. Although each

interview spanned an adequate amount of time to allow the entire semi-structured interview

schedule of questions to be administered, the inability to return for follow up interviews to both

clarify and provide depth to the original data may have enabled a more comprehensive description

of the accounts of the participants.

The final phase of the study achieved a relatively high number of participants; however it

does not represent every clinician available at MAPS at the time due to unplanned leave or long-

term absence due to illness or accrued holiday leave; so too only those with interest in the study

topic may have participated. Additionally, interviews were required to be conducted in the MAPS

office in order to meet the demands of a clinical workload. Accordingly, these interviews were

limited in time in order to be included in each participant’s work schedule. Although a focused

semi-structured tool was used (see Appendix D) meaning much useful data was garnered from the

clinician interviews, this remains a limitation of this methodology of interview.

As with all qualitative research, the findings documented in the final two phases represent

the subjective opinion of the participants. In exchange for the depth provided in this research

process, as mentioned in the opening paragraph of this section the ability to generalise these

findings to wider mental health settings or other mental health consumers is limited. In addition,

different results may be found in other mental health services in Australia or internationally. As a

result, this study remains exploratory in nature, providing a foundation for further research that will

be identified later in this chapter.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 288

Strengths of the Research

This study remains the only study in Australia to comprehensively examine the issue of dual

diagnosis in older adults in the setting of a community mental health service. Accordingly, it

addresses the issues associated with AOD use disorders in mental health services in relation to older

adults. It has also comprehensively described the published literature to date regarding dual

diagnosis in older adults. As strength, these attributes go some way to address the dearth of research

in this cohort in Australia.

As an exploratory study, this research project has built a foundation of evidence regarding

dual diagnosis in older adults. It remains somewhat of a seed study, in that it allows the knowledge

base surrounding this cohort to build on the exploratory nature of the findings. For example, the

study has determined that a population of older adults with dual diagnosis does exist within an inner

Melbourne community older adult mental health service, addressing the primary research question

posed in the introductory chapter of this thesis. Although there are some limitations to the

prevalence figure revealed, as described in the previous section, the file audit conducted as part of

phase one of this study demonstrates that a substantial number of consumers with complex needs

exist in MAPS.

The explanatory sequential nature of the study serves to add strength to the mixed

methodology framework employed in the formulation of this study. Each phase has informed the

next, for instance the results of the initial file audit served to influence the semi-structured

interviews of the second phase, and the responses of consumers to these questions formulated the

semi-structured questions posed to clinicians. As a result, the strength of the explanatory-sequential

framework serves to further expand and explain the findings of each phase of this research project,

in accordance with the fundamentals of the model as explained by Cresswell (2014).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 289

As described in the next section, a number of suggested research directions are a key

strength of this study. The second research question concerning the experiences of older adults with

dual diagnosis has been addressed, demonstrating the potential that the figures demonstrating that

older adults with dual diagnosis are largely a homogenous group of males who drink alcohol with

depression are not representative of the entire spectrum of older adults with dual diagnosis. Again,

this highlights the danger of homogeneity in treatment planning as discussed in the early stages of

this chapter.

Additionally, the second phase of this thesis provides an in-depth account into the lives of

six participants with complex dual diagnosis. It allows an understanding of the day-to-day

challenges these individuals face, in addition to demonstrating the frustrations and successes that

they have faced in their interactions with mental health services, AOD treatment services, and

healthcare providers in general.

Finally, addressing the third research question and considering the foundation of this study

is the very nature of the project itself: a service improvement project. The clinicians involved in the

third phase of this study had been empowered to suggest both shortfalls in the care provided to the

dual diagnosis cohort at MAPS and to suggest improvements in the care of these individuals.

Arguably, the greatest strength of this research is the power to enact change at a clinical level, as

discussed further in the next section of this chapter.

Recommendations for Future Research

The purpose of an explanatory-sequential framework is to explain a concept, and more

specifically, to provide context to a quantitative explanation using qualitative exploration (Kettles et

al., 2011). The results of this process of explanation lend themselves to provide a solid foundation

for further research to build greater knowledge in the concept under investigation. As a result, this
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 290

research project becomes somewhat of a seed study, providing the impetus for a number of further

investigations that are outlined in the following section.

Screening tools.

It is imperative that further research attempt to ascertain the benefit of contemporary

screening tools in respect of clinicians who may have competing assessment priorities and limited

time to conduct clinical interviews. It is a recommendation of this thesis that future research aims to

develop a screening tool that is timely and easy to administer. Additionally, the results should be

easily interpreted in the context of a holistic assessment. In respect of experienced mental health

clinicians as interviewed in the third stage of this study, this may take the form of a series of clinical

prompts that remind an assessor to ask around AOD use, with positive indicators requiring a more

comprehensive assessment at a later stage.

Additionally, it is recommended that a brief screening tool for dual diagnosis be developed

for settings other than mental health and AOD treatment. For instance, this may form a brief

questionnaire administered to older adults admitted to generalist hospital wards, or during

encounters with primary care. It is essential that this instrument is quick to administer and has a

supported referral pathway, as opposed to being a long screen that is rarely used, with an arbitrary

score that is entered and filed with no further action. This is an opportunity for MAPS or another

service provider to assume the screening and treatment planning for older adults who screen

positive to this instrument, in addition to incorporating brief intervention and health information

regarding sub-threshold alcohol consumption or problematic medication use.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 291

Specific cohort studies.

As mentioned earlier in this chapter, the contemporary literature surrounding mental ill

health and AOD use in older adults indicates that a number of distinct cohorts exist. An example of

this is demonstrated in the second phase of this study, with a participant indicating that a number of

her peers along with herself were undergoing methadone maintenance therapy and simultaneously

having occasional heroin use. Other cohorts include veterans, injecting drug users, sub-threshold

alcohol consumers living in retirement communities, socially isolated older people, those with

chronic pain who misuse pain medications, individuals who present to hospital with AOD related

injuries such as falls and the homeless. Repeating the second phase of this study with a recruitment

process targeting these specific cohorts may go some way to explaining their specific needs and

complexities in terms of treatment provision.

Considering recruiting to a longitudinal study may also go some way to demonstrate the true

cost of the combined complexities of mental ill health, AOD use and medical conditions. Ideally,

this longitudinal study should follow a key group of individuals at set intervals over a set time

period; similar studies have been completed with injecting heroin users (Darke et al., 2014) and

those who consume alcohol (Clemens, Matthews, Young, & Powers, 2007) and add much to the

knowledge base concerning these cohorts, in addition to shaping treatment methodologies.

Exploring adaptive use.

As demonstrated in both the second phase of this research project and prior work by Levy

and Anderson (2005), adaptive substance use is a concern among older adults. The propensity for

addiction careers to be fluid in nature, meaning periods of relapse and abstinence, in addition to

changes in substances used due to tolerance and availability are all cited as key factors in adaptive

substance use. Although adaptive use as a concept is apparent in the second phase of this thesis and
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 292

is identified by clinicians participating in the third phase, the understanding of the experience of

adaptive use in contemporary literature is poor.

It is a recommendation for further research that the notion of adaptive substance use is

comprehensively explored, specifically addressing and exploring changes in usage patterns over

time and better screening for inappropriate prescription medication use. Recognition that older

adults may adapt their use is essential in the provision of adequate treatment, and understanding this

process is essential to further knowledge regarding ongoing AOD treatment in the older adult

cohort. Further, exploring adaptive use may help clinicians to better understand points at which

older adults change their use, allowing them to implement strategies to assess readiness to change,

harm reduction and treatment engagement.

Cognitive impairment.

Cognitive impairment has long been recognised as an inevitable consequence of heavy

alcohol consumption (Sullivan & Pfefferbaum, 2005), however links to other substances, including

prescribed opiates and benzodiazepines are tenuous (Mintzer & Stitzer, 2002; Rapeli, Fabritius,

Kalska, & Alho, 2009, 2011). While research continues into the deleterious effect of these

substances on the ageing brain, clinicians require guidance in how to manage the effects of

cognitive impairment with those who continue to use AOD. This is especially pertinent when co-

occurring symptoms of mental ill health are present, making diagnosis and management of a triad

of issues extremely difficult.

It is a recommendation of this research that further work is done to explore screening for

cognitive impairment in older adults with dual diagnosis, in conjunction with work to discover

strategies for early intervention. Likewise, collaborative partnerships with acquired brain injury,

dementia or memory services should be explored; alcohol use should not preclude an individual
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 293

from investigation into their cognitive function, as has been experienced by this author and

clinicians working with older adults.

Specific treatment services.

Currently, virtually no treatment options specific to older adults exist (Hunter et al., 2010).

This leads to a system whereby complexity inherent in the older adult cohort is often not

manageable at the AOD treatment level. As described in Chapter Two of this thesis, Australia is

home to one single community AOD treatment service for adults aged 60 and over. Inpatient

detoxification and rehabilitation services may be loath to accept older adults due to this complexity,

leading to a substantive gap in service provision to older adults with dual diagnosis who require

specific AOD treatment.

Accordingly, the default option for treatment may fall to older adult mental health services,

or in the case of detoxification, general hospital wards. In fact, these settings may be the only

appropriate place to manage older adults who are withdrawing from substances due to a multitude

of medical complications requiring management. Further, the question of where to treat older adults

with significant complications of their AOD use arises; they may find themselves hospitalised after

injury and unable to return to their home, resulting in a form of treatment and accommodation in a

supported accommodation service that meets their level of care needs.

It is a recommendation of this research that specific treatment options for older adults are

investigated, not only in terms of specific settings, but protocols for managing dual diagnosis in the

general hospital setting. Given the costs involved in hospital treatment of older adults with dual

diagnosis, this research is urgently needed, particularly if predictions of a higher number of

presentations from the ageing baby boomer population eventuate as predicted (Colliver et al., 2006;

Johnson & Sung, 2013).

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 294

Comprehensive interventions.

A nurse participant mentioned in response to a question regarding their knowledge of harm

reduction in the third phase of this thesis that it should be a holistic approach: lifestyle, diet,

exercise and psychosocial. Accordingly, a range of comprehensive psychosocial interventions for

physical wellbeing have been trialled in the adult (aged under 65) consumer cohort, with some

promising results (Hasson-Ohayon, Kravetz, Roe, Rozencwaig, & Weiser, 2006; Richardson et al.,

2005). For example, Wynaden, Barr, Omari and Fulton (2012), conducted an exercise physiology

program with inpatients of a forensic psychiatric inpatient program in Western Australia, with

positive consumer feedback regarding psychiatric symptom control and subjective levels of

physical fitness and wellbeing. Additionally, in an older adult specific setting, a water exercise

group for people with dementia shows promise and subjective improvement across a number of

domains, albeit requiring scientific testing to determine efficacy (Neville, Clifton, Henwood,

Beattie, & McKenzie, 2013).

It is therefore a logical recommendation of this research that holistic interventions are

investigated. This becomes pertinent when investigating the issues associated with substance use

disorders, including poor nutrition and poor cardiovascular health. As illustrated in the first phase of

this study, many of the older adult mental health consumers at MAPS carried medical

comorbidities. Research should be conducted along the lines of that mentioned earlier which

examines the efficacy of community lifestyle groups incorporating exercise and skills such as

cooking healthy meals, both to provide older adults living independently with “recovery capital,”

and to provide a means of socialisation to address the isolation found in this cohort (Best & Laudet,

2010).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 295

Adapting harm reduction.

The final recommendation of this research involves harm reduction. As a concept, harm

reduction was initially geared towards injecting drug users, both as a means to reduce the

prevalence of blood borne viruses and to increase the take-up of opiate replacement therapies as a

means to mitigate the mortality in this group (Kellogg, 2003). Harm reduction has expanded to

include overdose treatments such as naloxone, and continues to push into new ground, including

novel ideas such as “pill testing” for individuals taking ecstasy at music festivals.

However, harm reduction seems to neglect older adults. For example, harm reduction in

older adults may encompass domains such as safety to drive, particularly with alcohol dependent

older adults whose baseline alcohol concentration may exceed that allowed for safe driving. It may

also address the risk of injury in the home from falls, financial vulnerability and injuries as a result

of misadventure. There is also scope to expand take home naloxone to older adults who misuse

prescription opiates (Kim & Nelson, 2015). Therefore, the final recommendation of this research is

that further study be conducted to expand contemporary harm reduction to strategies specific to

older adults with dual diagnosis.

Summary

This chapter has presented a comprehensive discussion of the issues identified during the

three-phase mixed methodology forming the research component of this thesis. It has aimed to

discuss these in line with the initial intent of this research project, being a service improvement

project designed to influence the practice of a community mental health service providing care to

older adults with dual diagnosis.

A number of recommendations for future research have also been presented in this chapter,

placing the current study as an exploratory “seed study:” in this respect, this document has provided
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 296

the evidence for future research to improve the care provided to older adults with dual diagnosis. A

number of future research directions are evident, and as argued in this chapter, imperative given the

potential for older adults with dual diagnosis to present in healthcare settings other than mental

health services. The final chapter describes recommendations for service improvement in line with

this aim, and the concluding statements of the thesis.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 297

Chapter Nine

Recommendations for Service Improvement and Concluding Statements

Introduction

The final chapter of this thesis presents recommendations in line with the overarching aim

of this research, being a service improvement project aiming to improve the care provided to older

adults with dual diagnosis who are receiving care from a community mental health service.

Accordingly, these improvements are structured at a service level, however are not limited to the

service discussed and researched in this thesis; similar research conducted in other mental health

services may find that areas where practice gaps exist may be improved by the implementation of

these recommendations.

Recommendations

The following seven recommendations have been formulated from the discussion and areas

requiring improvement evident during the three research phases of this thesis. They will be

discussed in the following section, including their implementation and potential limitations to the

recommendations. These are the major recommendations of the study, which may not necessarily

be applicable to other community mental health services that provide care to older adults with dual

diagnosis. They do, however, address a number of issues associated with providing care to older

adults with dual diagnosis and therefore are likely to improve the provision of care to this cohort in

other services with the issues identified in this study.

1. Screening

The first, and primary recommendation for practice arising from this research study is that

of screening. It is imperative that all individuals coming into contact with mental health services are
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 298

screened for co-occurring alcohol and other drug use; in fact, this edict was included in the

Victorian Government’s Key Directions (Victorian Government Department of Human Services,

2007) document, and forms a key criterion for services to be truly responsive to dual diagnosis.

Additionally, this recommendation should be expanded to screening all older adults for dual

diagnosis, no matter the severity, on all occasions of contact with healthcare providers. Research

has shown a propensity for a proportion of Australian older adults to consume alcohol in excess of

the guidelines for safe drinking (National Health and Medical Research Council, 2009), and

screening in this manner provides an opportunity to implement brief intervention in the form of

feedback tailored as a health improvement model. To this end, informing an individual that

reducing their alcohol consumption would be a positive benefit to their ongoing health is a non-

threatening manner of brief intervention (Leuenberger, Fierz, Hinck, Bodmer, & Hasemann, 2017;

Schonfeld et al., 2010).

Likewise, screening for illicit substances should be uniform. The outdated notion that older

adults simply do not use illicit drugs is a great disservice to those presenting to healthcare providers

and contributes to issues such as undetected withdrawal and delirium in general hospital settings

(Mayo-Smith, Beecher, Fischer, & et al., 2004). As mentioned in the recommendations for further

research section, initial screening for AOD use does not need to be comprehensive but the question

needs to be asked. A positive response should trigger referral to an appropriately skilled clinician to

further assess AOD use, determine the individual’s motivation to change and implement a treatment

plan prior to discharge from hospital. Case reports, including one arising from the creation of this

thesis, have shown good outcomes in implementing integrated treatment for dual diagnosis in

individuals who are hospital inpatients (Searby, van Swet, Maude, & McGrath, 2017).
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 299

2. Expanding practice domains

In accordance with the discussion on Setting contained in Chapter Eight, it is a

recommendation of this research that impetus be placed on expanding the practice domains of

contemporary older adult mental health services. In accordance with meeting the consumer where

they present, older adult mental health services should have a prominent presence in the treatment

and discharge planning of older adults with dual diagnosis in addition to providing specialist

assessment and support to staff who may not hold the skills or knowledge to provide care to this

cohort. This is particularly pertinent when considering nurses, who are often encouraged to

specialise and receive little mental health or addiction training during their undergraduate education

(Rassool, 2007).

Recognising that older adults with dual diagnosis may not necessarily be referred to mental

health services is key to expanding practice domains. A presence in community health services and

primary care is essential, and following on from the first recommendation in this section, allows a

speedy assessment and referral from the clinician who initially detects problematic AOD use and

mental ill health through screening. Time to treatment engagement has been shown to improve

ongoing treatment retention rates, and the literature demonstrates that older adults who use AOD

typically do very well in treatment (Oslin, Pettinati, & Volpicelli, 2002; Outlaw et al., 2012).

Likewise, treatment for mental ill health should be instituted in a timely fashion in order to ensure

favourable outcomes (McGorry, Yung, Phillips, & et al., 2002).

Expanding practice domains may mean the end of the traditional clinic model in older adult

mental health services, with clinicians becoming a more visible presence in the community. It may

also mean that they are required to liaise and consult closely with community organisations and

healthcare providers, participating in clinical meetings and providing secondary consultation in

order to be seen as a supportive and responsive presence. This form of collaborative partnership has
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 300

been demonstrated to lead to superior clinical outcomes (Craven & Bland, 2006; Dewa, Hoch,

Carmen, Gusscott, & Anderson, 2009), and will be discussed in greater detail in the next

recommendation.

Finally, in respect of expanding practice domains, it must be recognised that older adults

with mental illness who are managed by mental health services are simply not those who “graduate”

from adult community mental health services. The definition of mental ill health in older adults is

somewhat broader, encompassing organic disorders such as dementia, and a complex situation in

itself when compared with those under age 65 (Niederehe, 1998). This notion has been discussed

comprehensively throughout this thesis, however it is important to highlight that a system designed

to cater to younger adults may not necessarily be effective for their older counterparts.

3. Collaborative service linkages

The third recommendation for service improvement presented in this chapter is closely

intertwined with the second recommendation. Collaborative service linkages are essential to

provide competent, cohesive care for complex consumers such as older adults with dual diagnosis.

Perhaps the most pressing need to create collaborative service linkages is between mental health

services and AOD treatment services. Cultivating trust between clinicians is arguably a key

component of seamless referral, and aids in timely integration of treatment from the outset of the

individual’s episode of care. To achieve truly integrated treatment, as is recognised as the “gold

standard” in dual diagnosis treatment, it is essential to involve all stakeholders in the consumer’s

care from the point of assessment.

Developing collaborative service linkages enables timely information sharing and

communication. For instance, each service can communicate information about the state of their

treatment engagement and implementation as it occurs, as opposed to sending a referral form or

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 301

letter at the end of their episode of care. As evidenced by the first phase of this research project,

consideration of AOD treatment often did not occur in the initial phase of assessment and planning

for ongoing treatment. A collaborative service linkage could go some way to rectify this issue,

particularly given the third phase of the research project had clinicians identify that being able to

converse with AOD treatment services around appropriate referrals and treatment options offered

would likely increase their intention to refer to these services.

Collaborative linkages may also enable a streamlined assessment process. Contemporary

Victorian AOD assessment involves a large document, with many questions asked that are similar

to those asked by mental health clinicians (Department of Health, 2013b). Sharing of information

may reduce the burden on consumers, who are likely to be asked to repeat their symptoms, their

path to the mental health or AOD treatment service, their intention to change and their medical

history several times over multiple episodes of care. It would be easy to conclude that this is not

only a burden to consumers, but a deterrent to seeking ongoing treatment, however there is no

research specifically addressing this practice on treatment engagement and retention.

Finally, collaborative service linkages would allow a sharing of skills between mental health

and AOD treatment services. Although this thesis discusses a mental health service specifically,

literature indicates that AOD treatment services are frequently in need of support with complex

mental health presentations. A collaborative service linkage would allow this support and sharing of

knowledge to occur, with the ultimate benefit being to consumers who would be the chief recipients

of the advanced skills provided by both sets of clinicians.

4. Streamlining referral processes

Closely interrelated to the previous two recommendations, recommendation four of this

research project refers to streamlining referral processes. In some ways, this is a counterpoint to the
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 302

advantages of collaborative service linkages identified in the previous recommendation, however it

involves removing barriers to service entry for individuals felt to be in need of specialist mental

health care.

As described through the third phase of this thesis, the referral process for MAPS remains

cumbersome and often results in referrals for issues considered to be AOD related to be rejected.

This recommendation suggests that the referral process is streamlined, with provision for clinicians

to complete assessments with the sole goal of linking individuals with more appropriate services.

To some extent this model of care is practiced in other community-based services, including

Hospital Admission Risk Programs (HARP), who link individuals with ongoing care needs to

services in a brief case management model. Likewise, it would be prudent for MAPS to provide this

service to those who are deemed “not appropriate” for mental health services.

In the same vein, it is essential that older adult mental health services are seen as responsive

to referrals, rather than gatekeepers where it often appears that the sole aim is to reject as many

referrals as possible; this is a common complaint experienced by clinicians having to deal with

mental health services, and is supported by McEvoy and Richards (2007), whose qualitative work

with 29 clinicians responsible for gatekeeping in mental health services identified individuals with

AOD problems being triaged as least important and frequently denied service. As opposed to

rejecting referrals, it may be prudent to provide some support to clinicians that are struggling with

older adults with dual diagnosis through providing joint visits and making the referral process as

easy as possible.

Accordingly, the referral process should be streamlined for clinicians who are detecting dual

diagnosis in settings other than mental health. For instance, if the first recommendation of this

thesis is followed, then responding to reports of an older adult screening positive to dual diagnosis

or either mental ill health or problematic AOD use alone should trigger a comprehensive
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 303

assessment with a minimum of effort required for the referrer. Like screening, referral processes

should be simple and able to be completed in a minimum of time. Nursing, like many other health

professions, suffers from “mountains of paperwork,” with the end result being referrals not being

completed and screening tools either rushed through or not completed at all (Porter, Raja, Cant, &

Aroni, 2009). Therefore, streamlining this process removes a significant number of barriers to

nursing staff who have competing demands on their time. A supportive approach to community

clinicians who require assistance with older adults with dual diagnosis also results in a collaborative

approach, and ultimately better care for the individual in question.

5. Clinical specialisation

As discussed in Chapter Eight, the concept of clinical specialisation can potentially be a

double-edged sword in mental health services. On the one hand, it provides a team with a key

resource and contact who has the knowledge, qualifications and skill to manage older adults with

dual diagnosis. However, it can result in siloed care, with other clinicians referring all consumers

with dual diagnosis to the dedicated clinician for ongoing care, leading to a loss of skill and a

frustrated dual diagnosis clinician who feels that the work is simply “handballed” to them.

In spite of this issue, several clinician participants in the third phase of this research project

expressed a desire for the presence of a specialised clinician when discussing AOD issues in clinical

meetings and felt that this clinician would be of great support in both day to day management of

consumers with dual diagnosis and to provide ongoing education and training in the area. One way

of mitigating the danger of clinicians “siloing” their work is to employ a clinician in a consulting

role, which also addresses the issue of lone clinicians working with individuals with a high degree

of complexity by providing a skilled team member to assist. This method has reported success in

respect of the Clinical Nurse Consultant role (Humphreys, Johnson, Richardson, Stenhouse, &
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 304

Watkins, 2007), and therefore a recommendation of this research is that this role be explored in

terms of older adult mental health services.

Some healthcare services have gone as far as to develop addiction medicine teams who

provide a consultative approach within the entire hospital (McDuff et al., 1997), however the risk

with this approach is that they lose the immediate availability inherent in a team member who

operates locally with the multidisciplinary team. This position may have other responsibilities and

could logically operate as a support to enhanced screening as outlined in the first recommendation

of this chapter, however a key responsibility would be to provide support and consultation to the

older adult community mental health team. This could involve specialist assessment, brief

intervention and treatment, referral to AOD treatment services, advocacy and liaison with other

healthcare providers.

Regardless of the model that a service chooses, it is clear that some level of specialist input

is required when caring for older adults with dual diagnosis. The complexities inherent in their

presentations, coupled with the need for team based approaches and a degree of support in caring

for consumers with dual diagnosis as identified in the third phase of this research project makes the

recommendation that a clinical specialist be available to the mental health team easy to make.

6. Investigating appropriate treatment options

As discussed in Chapter Eight of this thesis, very few treatment options specific to older

adults exist in Australia. It is not only a recommendation of this research that ongoing investigation

be conducted into the viability of treatment options, but a recommendation for practice. Given the

service involved in this research, MAPS, has an attached 15 bed inpatient mental health unit, it is

recommended that this be explored as an option for inpatient detoxification for older adults with

dual diagnosis. Being attached to a medical hospital, it would allow medical supervision of those
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 305

admitted for this purpose, however the primary motivation in making this recommendation is the

current state of play of detoxification and rehabilitation facilities in Victoria.

At present, the waiting list for a treatment bed in a publically funded detoxification or

rehabilitation facility is lengthy, with many providers closing their doors to new applicants for

months at a time (Carr et al., 2008). This is at odds with the nature of addiction, where an

expression of a desire to change needs to be acted upon to allow an individual the greatest success

at modifying their AOD use and allowing treatment of mental ill health without the complication of

intoxication. Further, considering setting, it is likely that a number of older adults referred to MAPS

from the hospital itself have spent some time abstinent from AOD, thus putting them at risk of

relapse, and in the case of illicit substances, overdose leading to death (Tagliaro, Battisti, Smith, &

Marigo, 1998).

This research recommends investigating novel alternatives to long wait lists for treatment

services by utilising existing resources to allow older adults with dual diagnosis some “time out”

from their usual routines of AOD use, in turn allowing clinicians to implement appropriate therapies

and treatment to assist the individual to make changes to their substance use. Fortunately, many

consumers often contemplate ceasing or changing their AOD use in times of crisis, particularly in

the face of medical issues (Kirouac, Frohe, & Witkiewitz, 2015). As a result, utilising current

resources to allow them to make this change may pay dividends in the form of reduced service

utilisation and costs of care in the longer term.

This recommendation does not replace the call for research to determine the feasibility of

older adult specific treatment options, however it does recognise the current situation regarding

AOD treatment providers in Victoria and offers a solution to assist in the interim.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 306

7. Upskilling the workforce

The final recommendation of this research project, and arguably the most essential, is the

need to upskill the healthcare workforce who provide care to older adults with dual diagnosis. As

discussed previously in this chapter, contemporary research indicates a lack of undergraduate

education regarding AOD use in the healthcare context, and likewise, a number of studies have

identified experienced clinicians lamenting a lack of formal education in this area (Harling et al.,

2006; Novak & Petch, 1994; O'Gara et al., 2005). This research project has also identified this issue

among clinicians, with many of the participants in the third phase describing a lack of educational

preparation for working with older adults with dual diagnosis, and a need for practical, applicable

training.

Failing to provide clinicians with appropriate training is even more concerning given the

identified potential for older adults with dual diagnosis to present to a wide range of clinical

settings, therefore a key recommendation of this research project is that undergraduate nurses are

provided with education in order to at least consider the potential of co-occurring AOD use and

mental ill health in older adults in their chosen practice setting. This need not be formalised and

may take the format of novel approaches incorporating new technologies such as social media or

new devices to deliver relevant knowledge to enable neophyte clinicians to at least detect and make

appropriate referrals for older adults with dual diagnosis.

Likewise, it is essential that practising clinicians in mental health are provided with the

adequate ongoing education, training and support to enable them to provide competent, timely care

to older adults with dual diagnosis. Research has shown that providing a number of key training

elements increases the competency of dual diagnosis practice in clinicians in conjunction with

appropriate clinical support (Ford, Bammer, & Becker, 2009), and accordingly, truly making dual

diagnosis “core business” will not occur until this fundamental knowledge gap is addressed. In
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 307

addition, the consideration of a formalised supervision model, both to enable clinicians to discuss

their decision-making process and receive support for what is effectively a highly complex clinical

cohort should be integrated into mental health services. This effectively integrates with

Recommendation Five, whereby a key clinician may be appointed to provide this support to

members of the multidisciplinary team who are required to undertake case management of

consumers with dual diagnosis.

Concluding Statements

Dual diagnosis is a complex issue, poorly researched and shown to result in higher rates of

psychiatric relapse, more repeat admissions to hospital and ultimately higher financial costs of care.

In spite of these concerns, little contemporary research has examined dual diagnosis in older adults.

This is a concerning knowledge gap given the potential for an increase in co-occurring mental ill

health and AOD use in this cohort secondary to changing demographics and the ageing of the baby

boomer cohort. Additionally, the complex factors inherent in this cohort of individuals increases

their ongoing care needs, and is likely to cause a significant drain on the resources of healthcare

providers.

To date, many of the studies examining older adults with dual diagnosis have examined

specific populations in the United States of America, making these results difficult to apply to the

Australian situation. Blixen, McDougall and Suen’s (1997) study of older adults with dual

diagnosis in three inpatient psychiatric hospitals in the USA found a prevalence rate of co-occurring

AOD use in over a third of patients. This figure, representing over a third of patients in the mental

health service examined, is concerning given the current state of capability to provide competent

care for older adults with dual diagnosis identified in this thesis.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 308

Although this study did not find as high a prevalence rate in Caulfield Hospital MAPS, the

figure described in phase one of this research project demonstrates that in a two-year timeframe 92

individuals presented to this mental health service with complex needs that may not have been met.

Reiterating a key limitation of this study, this figure may be relatively conservative due to the lack

of comprehensive screening for alcohol and other drug use. The third phase of this project

demonstrates that this is not a satisfactory situation, with some clinicians describing asking about

AOD as a uniform practice and others relying on observation or their judgement on whether it was

appropriate to address the issue with a specific client. Despite these limitations, this finding has

addressed the initial research question guiding this study by demonstrating that a population of

older adults with dual diagnosis do exist within Caulfield Hospital MAPS.

The second phase of the study allowed consumers with dual diagnosis to describe their

experiences with mental ill health, alcohol and other drug use and interactions with mental health

and AOD treatment services. It achieved the aim of the second research question, being an

examination of the experiences of consumers with dual diagnosis in the mental health service.

Although limited by a small sample, these individuals were selected in conjunction with case

managers who identified them as being particularly challenging to work with due to their

complexity. Accordingly, this sample provides an opportunity for learning and has challenged other

research findings, including those from the first phase of this study, that older adults with dual

diagnosis are largely a homogenous group of males who consume alcohol with an affective disorder

such as depression.

This research project remains the only known study exploring dual diagnosis in Australian

older adults in the context of a specific mental health service in Melbourne. Although this limits

generalisation of the findings, it provides an in-depth account of the experiences of both consumers

of the mental health service with dual diagnosis, and the clinicians providing care to them.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 309

Accordingly, this thesis is able to offer a number of recommendations at the service level to

improve the care to this cohort, addressing the third research question posed in the introduction to

this study. The clinicians participating in this study identified a number of key factors impeding the

provision of care to older adults with dual diagnosis and were able to make a number of suggestions

for the improvement of this care. Perhaps the most pertinent of these suggestions was a desire for

service leaders to embed dual diagnosis in their organisational culture, ensuring that clinicians were

encouraged and supported to consider dual diagnosis as part of their assessment and ongoing care.

This research project has a number of policy implications for local health services, including

service changes as discussed above. Reflecting on the Victorian Government’s Key Directions

(2007) document, it is clear that the service that is the focus of this study has not made dual

diagnosis “core business,” nor has it met a number of principles outlined in this document.

Similarly, this thesis demonstrates the potential for older adults to present in a wide variety of

healthcare settings, truly challenging the contemporary service model of provision of mental health

care to older adults with dual diagnosis; this is shown in the second phase of this thesis, where the

consumer participants described a wide range of interactions with healthcare providers. Of most

concern, the question must be raised that if a mental health service has difficulty identifying and

managing individuals with dual diagnosis, how severe are the service gaps in other areas of

healthcare?

A number of recommendations were made in both Chapter Eight and the current chapter of

this thesis, aimed at improving treatment outcomes for older adults with dual diagnosis. As an

exploratory study, this research project provides a solid foundation to embark on broader research

and indicated in Chapter Eight. This research is fundamental to enhancing the understanding of

older adults with dual diagnosis, and ultimately improving the care provided to them in

contemporary healthcare settings. However, as a standalone document, this project has achieved its
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 310

ultimate aim of providing suggestions for service improvement, namely the implementation of

uniform screening procedures, altering the service delivery model to meet the consumer at the point

of presentation and improving both knowledge and practical skills amongst the clinicians who

provide care to the older adults with dual diagnosis who present to the healthcare service.

Finally, as a clinician, this research project has influenced my practice in a number of ways.

Following Leeman and Sandelowski’s (2012) vision of “practice-based evidence” has allowed me

to identify an area of clinical practice that I felt was lacking, explore it in depth and formulate

recommendations that fit in the contemporary model of healthcare, which requires solutions that are

cost effective and involve clinician “buy in” to have a chance of success. To this end, the results of

this study have allowed me to move into a role which allows me to implement some of the

recommendations in this thesis in a wider healthcare context and provide education to clinicians in

both identifying and caring for older adults in the general hospital who have dual diagnosis.

Likewise, this service is largely supportive of ongoing research into the care of older adults with

dual diagnosis and AOD use generally, allowing me to truly achieve the vision of building an

evidence base on the foundation of exploratory discourse contained in this thesis.

To conclude, dual diagnosis in older adults is a complex issue, and one that is likely to

increase in contemporary healthcare services due to an ageing baby boomer cohort and changing

demographics. Therefore, now is the time to both devise solutions to improving the care of older

adults with dual diagnosis and increasing the knowledge base and practical skills of clinicians

providing care to this cohort. Beyond the service involved in this study, it is imperative that this

process commences in neophyte clinicians, in order to reduce the tendency for older adults with

dual diagnosis to become a hidden epidemic.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 311

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participating in an exercise programme at the Western Australian State Forensic Mental

Health Services. International Journal of Mental Health Nursing, 21(3), 229-235.

Yücel, M., Lubman, D. I., Harrison, B. J., Fornito, A., Allen, N. B., Wellard, R. M., . . . Pantelis, C.

(2007). A combined spectroscopic and functional MRI investigation of the dorsal anterior

cingulate region in opiate addiction. Molecular Psychiatry, 12(7), 691-702.

Zanjani, F., & Rowles, G. D. (2012). “We don't want to talk about that”: Overcoming barriers to

rural aging research and interventions on sensitive topics. Journal of Rural Studies, 28(4),

398-405.

Zuckerman-Parker, M., & Shank, G. (2008). The town hall focus-group: A new format for

Qualitative research methods. The Qualitative Report, 13(4), 630-635.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 353

Appendix A: Ethical Approval Statements

ETHICS COMMITTEE CERTIFICATE OF APPROVAL

This is to certify that

Project No: 110/14

Project Title: Dual diagnosis in older adults: A hidden epidemic?

Principal Researcher: A/Professor Phillip Maude

Protocol Version 1.3 dated: April 2014

Participant Information and Consent Form (Clients) Version 1.3 dated: May 2014
Participant Information and Consent Form (Staff) Version 1.3 dated: May 2014

was considered by the Ethics Committee on 1-May-2014, meets the requirements of the
National Statement on Ethical Conduct in Human Research (2007) and was APPROVED on 27-May-2014

It is the Principal Researcher’s responsibility to ensure that all researchers associated with this project are aware of the
conditions of approval and which documents have been approved.

The Principal Researcher is required to notify the Secretary of the Ethics Committee, via amendment or progress
report, of

Any significant change to the project and the reason for that change, including an indication of ethical implications
(if any);
Serious adverse effects on participants and the action taken to address those effects;
Any other unforeseen events or unexpected developments that merit notification;
The inability of the Principal Researcher to continue in that role, or any other change in research personnel involved
in the project;
Any expiry of the insurance coverage provided with respect to sponsored clinical trials and proof of re-insurance;
A delay of more than 12 months in the commencement of the project; and,
Termination or closure of the project.

Additionally, the Principal Researcher is required to submit

A Progress Report on the anniversary of approval and on completion of the project (forms to be provided);

The Ethics Committee may conduct an audit at any time.

All research subject to the Alfred Hospital Ethics Committee review must be conducted in accordance with the National
Statement on Ethical Conduct in Human Research (2007).

The Alfred Hospital Ethics Committee is a properly constituted Human Research Ethics Committee in accordance with the
National Statement on Ethical Conduct in Human Research (2007).

SPECIAL CONDITIONS

None SIGNED:

R Frew
Secretary, Ethics Committee

Please quote project number and title in all correspondence

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 354

RMIT University

Science Engineering
and Health

College Human Ethics

Advisory Network
th
17 June 2014 (CHEAN)

Plenty Road
Bundoora VIC 3083

PO Box 71
Bundoora VIC 3083
Phillip Maude Australia
Building 201 Level 7, Room 16
School of Health Sciences Tel. +61 3 9925 7096
Fax +61 3 9925 6506
RMIT University • www.rmit.edu.au

Dear Phillip,

ASEHAPP 39-14 MAUDE SEARBY Dual diagnosis in older adults: A hidden epidemic?

Thank you for submitting your application for consideration by the Science, Engineering and Health College
Human Ethics Advisory Network (CHEAN) of RMIT University.

Your application was considered at the meeting 05 – 14 on, Wednesday 2014. The CHEAN notes that this
project has been approved by the Human Research Ethics Committee from The Alfred Hospital

With research projects that involve applications to more than one Human Research Ethics Committee (HREC),
the Science, Engineering and Health College Human Ethics Advisory Network (CHEAN) adopts the following
policy:

Where a research project is submitted to more than one HREC, one of those HRECs will be designated the
primary HREC. The primary HREC will be the HREC associated with the organisation that has the primary
ethical duty of care over the research participants.

In the event that the Science, Engineering and Health CHEAN is not the primary HREC, its role will be to
endorse and affirm the decision of the primary HREC, provided the primary HREC is properly constituted under
Australian Health Ethics Committee and National Heath and Medical Research Council guidelines.

To do this, the Science, Engineering and Health CHEAN requires a copy of all documentation associated with
the application to the primary HREC, including letters of approval. The Science, Engineering and Health
CHEAN reserve the right to request changes to the ethical conduct of the research in order to meet RMIT
University requirements.

In the case of your research project, the Science, Engineering and Health CHEAN has received a copy of all of
the documentation related to your application to the human research ethics committee noted above; therefore, the
Science, Engineering and Health CHEAN is able to endorse and affirm the decision of that committee.

If you have any questions about this letter or about any ethical issues that arise during the conduct of your
research, please contact the Chair of the CHEAN directly.

Yours sincerely

Linda Jones
Chair, Science Engineering & Health
College Human Ethics Advisory Network

Cc Other Investigator/s: Ian McGrath School of Health Sciences RMIT University

Student Investigator: Adam Searby s9869047A School of Health Sciences RMIT University
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 355

Appendix B: Participant Information and Consent Forms (PICFs)

Participant Information Sheet/Consent Form

Non-Interventional Study – Adult providing own consent

Caulfield Hospital Mobile Aged Psychiatry Service (MAPS)

Title Dual diagnosis in older adults: A hidden epidemic?

Short Title Dual diagnosis in older adults
Principal Investigator Associate Professor Phil Maude
Associate Investigators Dr Ian McGrath
Adam Searby
Location Caulfield Hospital

Part 1 What does my participation involve?

1 Introduction
You are invited to take part in this research project, Dual diagnosis in older adults: A hidden epidemic? This
study aims to explore the experiences of a small number of individuals who use MAPS services in depth, by
describing their stories of drug and alcohol use, their experiences of using services like MAPS and
examining their medical histories that are held by MAPS. This research project is aiming to improve the
service experience of individuals case managed by MAPS who use alcohol and other drugs.

This Participant Information Sheet/Consent Form tells you about the research project. It explains the
research involved. Knowing what is involved will help you decide if you want to take part in the research.

Please read this information carefully. Ask questions about anything that you don’t understand or want to
know more about. Before deciding whether or not to take part, you might want to talk about it with a
relative, friend or local doctor.

Participation in this research is voluntary. If you don’t wish to take part, you don’t have to. You will receive
the best possible care whether or not you take part.

If you decide you want to take part in the research project, you will be asked to sign the consent section. By
signing it you are telling us that you:
• Understand what you have read
• Consent to take part in the research project
• Consent to research that is described
• Consent to the use of your personal and health information as described

You will be given a copy of this Participant Information and Consent Form to keep.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 356

2 What is the purpose of the research?

Currently, there is very little research exploring the experiences of older adults who use alcohol and other
drugs in Melbourne. The aim of this study is to use these individual experiences, along with detailed case
histories, to identify better ways to care for MAPS clients who use alcohol and other drugs. The student
researcher, Adam Searby, will also use the results of this research to obtain a Doctor of Philosophy degree
from RMIT University.

3 What does participation in this research involve?

The initial steps in this project will involve case managers identifying participants who do, or have used,
alcohol or other drugs and who are willing to participate in this project. If you agree to take part in this
project, you will be asked to participate in 1-3 interviews with up to two of the investigators from the study
team. These interviews will be of 1-2 hours duration, and will ask you a number of questions to help you tell
your story of your experiences of MAPS, using drugs or alcohol and your mental health. These interviews
will be recorded using audio recording equipment for the purposes of transcribing your interview onto paper,
and the interviews themselves will take place in your home, the MAPS clinic or another private place agreed
to by yourself and the research team. All identifiable information, such as your name, address and hospital
identification number, will be removed from the published research.

You will also be asked to consent to researchers examining your medical history as held by the hospital. This
is to help build a clinical picture to go with the answers you provide to questions during the interview
process.

This research project has been designed to make sure the researchers interpret the results in a fair and
appropriate way that avoids study researchers or participants jumping to conclusions.

There are no costs associated with participating in this research project. You will be reimbursed $25 per
interview in line with Alfred Health research policy.

4 What do I have to do?

Your only requirement to participate in this study is to provide 1-3 interviews with the research team, of 1-2
hours duration. There will be no restrictions on your lifestyle, diet or medication, and your care with MAPS
will proceed as usual.

5 Other relevant information about the research project

The project involves reviewing MAPS records to identify a percentage (the prevalence) of individuals case
managed or assessed by the MAPS team using alcohol or drugs, individual interviews with 6-10 individuals
and finally, an interview process with MAPS staff. It is anticipated that this process will both identify
shortfalls in the current care of individuals case managed by MAPS who use alcohol and drugs, and guide
future care to be more responsive to the needs of the individual.

6 Do I have to take part in this research project?

Participation in any research project is voluntary. If you do not wish to take part, you do not have to. If you
decide to take part and later change your mind, you are free to withdraw from the project at any stage.

If you do decide to take part, you will be given this Participant Information and Consent Form to sign and
you will be given a copy to keep.

7 What are the possible benefits of taking part?

We cannot guarantee or promise that you will receive any benefits from this research, however
possible benefits may include the opportunity to participate in a process where clients of MAPS have
the opportunity to identify – and suggest remedies to rectify – concerns, problems and failings with
the care provided to those who use drugs and alcohol.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 357

8 What are the possible risks and disadvantages of taking part?

The major risk of participation in this project is that you are providing information to the researcher that
could potentially be incriminating. This information, or your participation, will not be disclosed unless a
court order or mandatory reporting obligation exists. In the event that Alfred Health is required to disclose
this information, it may be used against you in legal proceedings or otherwise.

If you become upset or distressed as a result of your participation in the research, the study researcher will be
able to arrange for counselling or other appropriate support. Any counselling or support will be provided by
qualified staff that are not members of the research project team. This counselling will be provided free of
charge.

9 What if I withdraw from this research project?

If you do consent to participate, you may withdraw at any time. If you decide to withdraw from the project,
please notify a member of the research team before you withdraw. A member of the research team will
inform you if there are any special requirements linked to withdrawing. If you do withdraw, you will be
asked to complete and sign a ‘Withdrawal of Consent’ form; this will be provided to you by the research
team.

If you decide to leave the research project, the researchers will not collect additional personal information
from you, although personal information already collected will be retained to ensure that the results of the
research project can be measured properly and to comply with law. You should be aware that data collected
up to the time you withdraw will form part of the research project results. If you do not want your data to be
included, you must tell the researchers when you withdraw from the research project.

10 What happens when the research project ends?

When the research project ends, your care by the MAPS team will continue. MAPS case managers will be
provided with de-identified results, which will be available for you to read if you wish to find out about the
success of the project.

Part 2 How is the research project being conducted?

11 What will happen to information about me?

By signing the consent form, you consent to the research team collecting and using personal information
about you for the research project. Any information obtained in connection with this research project that can
identify you will remain confidential. Information that may contain confidential information, such as your
name, age, and hospital identification number, will be kept in a locked office at RMIT University, Bundoora.
It will also be encrypted and password protected when kept on computers associated with this project.
Likewise, audio recordings will remain encrypted and password protected, and only available to the research
team and audio typist for the purpose of transcription.

Your information will only be used for the purpose for this research project and it will only be disclosed with
your permission, except as required by law.

Information about you may be obtained from your health records held at this and other health organisations
for the purpose of this research. By signing the consent form you agree to the research team accessing health
records if they are relevant to your participation in this research project.

Your health records and any information obtained during the research project may be subject to inspection
(for the purpose of verifying the procedures and the data) by authorised representatives of the institutions
relevant to this Participant Information Sheet, Alfred Health and RMIT University, or as required by law. By
signing the Consent Form, you authorise release of, or access to, this confidential information to the relevant
research personnel and regulatory authorities as noted above.
 DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 358

This information will be de-identified as best as possible. This means your name, hospital record number or
any other information that may identify you will be removed. Despite every best effort being made to de-
identify your information, it may be possible that you may be recognised through your responses. This is a
small risk of qualitative research, although it is one you should be aware of when making your decision to
participate.

It is anticipated that the results of this research project will be published and/or presented in a variety of
forums. In any publication and/or presentation, information will be provided in such a way that you cannot
be identified, except with your express permission.

12 Who is organising and funding the research?

This research project is being conducted by Adam Searby. It is being funded by an Australian Postgraduate
Award research scholarship provided by both the Australian Government and RMIT University.

13 Who has reviewed the research project?

All research in Australia involving humans is reviewed by an independent group of people called a Human
Research Ethics Committee (HREC). The HREC of Alfred Health has approved the ethical aspects of this
research project.

This project will be carried out according to the National Statement on Ethical Conduct in Human Research
(2007). This statement has been developed to protect the interests of people who agree to participate in
human research studies.

14 Further information and who to contact

The person you may need to contact will depend on the nature of your query. If you want any further
information concerning this project or if you have any problems that may be related to your involvement in
the project, you can contact either of the following people:

Research Contacts
Name Associate Professor Phil Maude
Position Principal Researcher
Telephone 9925 7447

Name Adam Searby

Position Registered Nurse/PhD Candidate
Telephone 9076 6627
Email [email protected]

If you have any complaints about any aspect of the project, the way it is being conducted or any questions
about being a research participant in general, then you may contact:

Complaints contact person

Name Emily Bingle
Position Research Governance Officer
Telephone 9076 3619
Email [email protected]

You will need to tell Ms Bingle the following Alfred Health project number: 110/14.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 359

Consent Form - Adult providing own consent

Title Dual diagnosis in older adults: A hidden epidemic?
Short Title Dual diagnosis in older adults
Principal Investigator Associate Professor Phil Maude
Associate Investigators Dr Ian McGrath
Adam Searby
Location Caulfield Hospital

Declaration by Participant

I have read the Participant Information Sheet or someone has read it to me in a language that I understand.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I freely agree to participate in this research project as described and understand that I am free to withdraw at
any time during the project without affecting my future care.
I understand that I will be given a signed copy of this document to keep.

Name of Participant (please print)

Signature Date

☐ Please tick this box to indicate your consent to audio recording during interview.

☐ Please tick this box if you would like a summary of the research at the end of the research project.

Declaration by Researcher†
I have given a verbal explanation of the research project, its procedures and risks and I believe that the
participant has understood that explanation.

Name of Researcher† (please print)

Signature Date
†
An appropriately qualified member of the research team must provide the explanation of, and information concerning, the research
project.

Note: All parties signing the consent section must date their own signature.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 360

Participant Information Sheet/Consent Form

Non-Interventional Study – Adult providing own consent

Caulfield Hospital Mobile Aged Psychiatry Service (MAPS)

Title Dual diagnosis in older adults: A hidden epidemic?

Short Title Dual diagnosis in older adults
Principal Investigator Associate Professor Phil Maude
Associate Investigators Dr Ian McGrath
Adam Searby
Location Caulfield Hospital

Part 1 What does my participation involve?

1 Introduction
You are invited to take part in this research project, Dual diagnosis in older adults: A hidden epidemic? This
study aims to explore the experiences of a small number of individuals who use MAPS services in depth, by
describing their stories of drug and alcohol use, their experiences of using services like MAPS and
examining their medical histories that are held by MAPS. This research project is aiming to improve the
service experience of individuals case managed by MAPS who use alcohol and other drugs.

This Participant Information Sheet/Consent Form tells you about the research project. It explains the tests
and research involved. Knowing what is involved will help you decide if you want to take part in the
research.

Please read this information carefully. Ask questions about anything that you don’t understand or want to
know more about. Participation in this research is voluntary. If you don’t wish to take part, you don’t have
to.

If you decide you want to take part in the research project, you will be asked to sign the consent section. By
signing it you are telling us that you:
• Understand what you have read
• Consent to take part in the research project
• Consent to research that is described
• Consent to the use of your personal and health information as described

You will be given a copy of this Participant Information and Consent Form to keep.

2 What is the purpose of the research?

Currently, there is very little research exploring the experiences of older adults who use alcohol and other
drugs in Melbourne. The aim of this study is to use these individual experiences, along with detailed case
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 361

histories, to identify better ways to care for MAPS clients who use alcohol and other drugs. The student
researcher, Adam Searby, will also use the results of this research to obtain a Doctor of Philosophy degree
from RMIT University.

3 What does participation in this research involve? What do I have to do?

If you agree to participate in this project, you will be required to participate in one or more semi
structured interviews exploring the themes associated with dual diagnosis in older adults. A semi
structured interview involves the researcher asking a number of open-ended questions related to the
topic of investigation.

Interviews will be recorded using audio recording equipment to assist with transcription at a later
time. The student researcher or a qualified staff member of RMIT University will perform
transcription.

4 Other relevant information about the research project
The project involves reviewing MAPS records to identify a percentage (the prevalence) of individuals case
managed or assessed by the MAPS team using alcohol or drugs, individual interviews with 6-10 individuals
and finally, an interview process with MAPS staff. It is anticipated that this process will both identify
shortfalls in the current care of individuals case managed by MAPS who use alcohol and drugs, and guide
future care to be more responsive to the needs of the individual.

5 Do I have to take part in this research project?

Participation in any research project is voluntary. If you do not wish to take part, you do not have to. If you
decide to take part and later change your mind, you are free to withdraw from the project at any stage.

If you do decide to take part, you will be given this Participant Information and Consent Form to sign and
you will be given a copy to keep.

6 What are the possible benefits of taking part?

The benefits associated with participation include the opportunity to participate in a process where
case managers and clinicians have the opportunity to identify - and suggest remedies to rectify -
concerns, problems and failings with care of the dually diagnosed client. Participants in the project will
be invited to discuss suggestions to improve client management and contribute to the
recommendations of the research.

7 What are the possible risks and disadvantages of taking part?
As previously mentioned, the major risk of participation is that of embarrassment and conflict of
opinions and values. However, the risks are small given the informal debriefing process health
professionals engage in when managing stressful incidents. It is likely that you have discussed these
incidents with your peers previously.

There may be a possibility that you are upset, distressed or concerned about discussions that have
taken place during the interview process. In this instance, you should contact peer support co-
ordinator Anne Howell confidentially, on extension 66127 as soon as convenient. Anne will discuss
your concerns with you confidentially and suggest appropriate follow-up if necessary. Alternatively,
you may contact PPC International, the Employee Assistance Provider for Alfred Health, on 1300 361
008.

All responses will be treated with utmost confidentiality, and transcripts will be recorded using
pseudonyms. Under no circumstances will identifiable information be available to parties other than
the researcher and research supervisors. Despite all of these measures, confidentiality cannot be
guaranteed. You may be identified by the responses or commentary you provide during the interview.

 DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 362

8 What if I withdraw from this research project?

If you do consent to participate, you may withdraw at any time. If you decide to withdraw from the project,
please notify a member of the research team before you withdraw. A member of the research team will
inform you if there are any special requirements linked to withdrawing. If you do withdraw, you will be
asked to complete and sign a ‘Withdrawal of Consent’ form; the research team will provide this to you.

If you decide to leave the research project, the researchers will not collect additional personal information
from you, although personal information already collected will be retained to ensure that the results of the
research project can be measured properly and to comply with law. You should be aware that data collected
up to the time you withdraw will form part of the research project results. If you do not want your data to be
included, you must tell the researchers when you withdraw from the research project.

Part 2 How is the research project being conducted?

9 Who is organising and funding the research?
This research project is being conducted by Adam Searby. It is being funded by an Australian Postgraduate
Award research scholarship provided by both the Australian Government and RMIT University.

10 Who has reviewed the research project?

All research in Australia involving humans is reviewed by an independent group of people called a Human
Research Ethics Committee (HREC). The HREC of Alfred Health has approved the ethical aspects of this
research project.

This project will be carried out according to the National Statement on Ethical Conduct in Human Research
(2007). This statement has been developed to protect the interests of people who agree to participate in
human research studies.

11 Further information and who to contact

The person you may need to contact will depend on the nature of your query. If you want any further
information concerning this project or if you have any problems that may be related to your involvement in
the project, you can contact either of the following people:

Research Contacts
Name Associate Professor Phil Maude
Position Principal Researcher
Telephone 9925 7447

Name Adam Searby

Position Registered Nurse/PhD Candidate
Telephone 9076 6627
Email [email protected]

If you have any complaints about any aspect of the project, the way it is being conducted or any questions
about being a research participant in general, then you may contact:

Complaints contact person

Name Emily Bingle
Position Research Governance Officer
Telephone 9076 3619
Email [email protected]

You will need to tell Ms Bingle the following Alfred Health project number: 110/14.
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 363

Consent Form - Adult providing own consent

Title Dual diagnosis in older adults: A hidden epidemic?

Short Title Dual diagnosis in older adults
Principal Investigator Associate Professor Phil Maude
Associate Investigators Dr Ian McGrath
Adam Searby
Location Caulfield Hospital

Declaration by Participant
I have read the Participant Information Sheet or someone has read it to me in a language that I understand.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I freely agree to participate in this research project as described and understand that I am free to withdraw at
any time during the project without affecting my future care.
I understand that I will be given a signed copy of this document to keep.

Name of Participant (please print)

Signature Date

☐ Please tick this box to indicate your consent to audio recording during interviews.

Declaration by Researcher†
I have given a verbal explanation of the research project, its procedures and risks and I believe that the
participant has understood that explanation.

Name of Researcher† (please print)

Signature Date
†
An appropriately qualified member of the research team must provide the explanation of, and information concerning, the research
project.

Note: All parties signing the consent section must date their own signature.
FILE AUDIT TOOL
Dual Diagnosis in Older Adults: A Hidden Epidemic?
Date of Admission/Assessment: M F Diagnosis:
Code: Age: Sex:

Suburb:

Intake Assessment
Medical conditions: Narrative Review:
“Yes” recorded Further details of substance use
in AOD section
in risk
Appendix C: File Review Tool

assessment?
If no, continue to
next section.

Not
Substance (if indicated) ETOH THC BZDs Opiates Other:
indicated

91 Day/Clinical Review (if no intake assessment)

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC?

Medical conditions: Narrative Review:

Further details of substance use
Narrative
indicates
substance use?
If no, continue
to next section.

Not
Substance (if indicated) ETOH THC BZDs Opiates Other:
indicated

HoNOS Data
Admission 91 Day 1 91 Day 2 91 Day 3 91 Day 4 91 Day 5 91 Day 6 Discharge

Episode
HoNOS Score
Item 3. Score
Problem
Drinking or
Drug-Taking
Date

Dual Diagnosis in Older Adults_File Audit Tool_Version 1.0_February 2014

364
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 365

Appendix D: Semi-Structured Interview Questions

Client Interview Guide1
(Key questions and possible prompts to explore further responses)

Questions are to be guided by case history review, and reflective listening process during the interview itself.
Ultimately, the aim is for an informal conversational interview rather than attempting to complete a prescribed list of
questions. These guidelines are therefore intended as an index of topics and possible questions that may be utilised to
stimulate discussion during the interview itself.

• Exploration of drug career trajectory

o Although likely apparent through medical history, explore:
1. Age of onset of each substance
2. Past and current substance use (see substance use matrix)
3. Periods of abstinence
4. Current patterns of use
5. Mode of use (regular or binge use)
• Client’s observations/narrative on drug use
o Intended to cover the client’s personal views and experiences of their own substance use. Where
appropriate, explore:
§ Onset of substance use. At what age did you start using drugs/alcohol?
§ Circumstances leading to substance use. What were the circumstances surrounding your
commencement of drug/alcohol use?
§ Personal history, i.e. Family, schooling, employment, developmental. How would you
describe your family life/school/work when you began using substances? What happened to
your family life/school/work after you started using substances?
§ Client’s observations of effect of substance use on life/lifestyle. How has using
drugs/alcohol affected your life?
• Effects of drug use
o Intended to further explore effects of drug use on individual.
§ Involvement in crime or arrest. Have you ever been arrested or been involved with crime
related to your drug/alcohol use?
§ Physical health. Has your physical health been affected due to your use of drugs or alcohol?
§ Financial effects. How have you financed your use of drugs/alcohol? (Possible overlap with
crime/work history).
§ Social effects. Has your use of drugs/alcohol had effects on your friends/family? How has
your use impacted on relationships?
• Mental health
o Intended to explore the client’s experience of mental illness and diagnosis.

1 Based on format presented in Patton, M., (2002). Qualitative Research and Evaluation Methods, California: Sage

Publications. Pg. 419-421.

DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 366

§ Age and experience of diagnosis. At what age were you first diagnosed/hospitalised due to
mental illness? What happened leading up to this? What happened at the time?
§ Substance use at time of diagnosis. Were you using drugs/alcohol in the lead up to your
diagnosis/hospitalisation?
• Effects of substance use on mental health
o Intended to explore client’s perceptions of substance use on mental health.
§ Perceptions of use and mental health. Do you think that using substances affects your mental
health? How?
§ Substance use leading to diagnosis. Do you think drug/alcohol use led to you becoming
mentally unwell? How?
§ Substance use and relapse. There is a lot of research that says that using drugs/alcohol may
lead to your mental state becoming worse. Do you agree with this? Why/why not?
• Experiences of services
o Intended to explore client’s experiences of MAPS/other services in relation to their substance use.
§ Understanding. What are your experiences of telling your case manager/clinicians about
your substance use? Did you feel supported/understood?
§ Assistance to cease use. Have you ever asked your case manager/clinicians to help you stop
using drugs/alcohol? Did you feel supported/understood? Were you referred to appropriate
services to assist with this process?
§ Harm reduction. Have you disclosed that you currently use drugs/alcohol to your case
manager/clinician? Did you feel supported/understood? Sometimes, harm reduction
strategies such as controlled use/needle exchanges/overdose awareness can make using
drugs/alcohol safer. Did your case manager/clinician help you with any of these?
• If client in supported accommodation, explore staff attitudes to continued use and
support.
§ Overall satisfaction with MAPS/other services. Do you feel that mental health services are
able to help you with substance use? Can you tell me your experience of being a client of
MAPS with both a mental illness diagnosis and drug/alcohol use?
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 367

§
Substance Use Matrix2

Days used in past month

Days used in past week

Days injected in past

Age of regular use

Average daily use

Age at first use

Route of use

Last use
month
Substance

Alcohol

Cannabis

Amphetamine
type stimulants

Inhalants

Sedatives or
sleeping pills
Prescribed? ☐

Hallucinogens

Opioids
Prescribed? ☐

Other (ie
cocaine, GHB)

2 Based on Victorian Department of Health AOD Comprehensive Assessment tool (2013). Accessed at
http://www.turningpoint.org.au/Treatment/For-Health-Professionals/New-screening-and-assessment-
tools1.aspx
DUAL DIAGNOSIS IN OLDER ADULTS: A HIDDEN EPIDEMIC? 368

Semi-Structured Interview Questions

Staff Interviews
(Key questions and possible prompts to explore further responses)

Do you feel confident in assessing and recognising clients’ substance abuse?

• Can you describe how you would assess for substance abuse?
• Are you aware of any tools available to assist with assessing for substance abuse? Can you name and describe
any of these tools?
• Do you feel that MAPS, as a service, is doing enough to identify dual diagnosis clients?
• Can you describe any factors where certain cues may have led you to believe substance abuse was occurring
(during an assessment or home visit)?

How do you feel clients with dual diagnosis in MAPS are managed?
• Do you think enough is done to support clients wishing to cease their use of substances?
• Can you describe a situation where you feel a dual diagnosis client was managed well?
• How about describing a situation where a dual diagnosis client was managed poorly?

How do you feel personally about case managing clients with dual diagnosis?
• How do you feel about your level of knowledge and skill in case managing those who abuse substances?
• Could you confidently refer clients to appropriate AOD services if they told you they wanted help to cease
their substance use?
• Could you describe your idea of harm minimisation in clients who continue to use substances?
• How would you implement strategies to minimise harm related to drug use?

How could we improve as a service?

• How could we assess dual diagnosis better?
• How could we case manage clients who abuse substances better?
• Given the potential for an increase in dually diagnosed clientele, do you think MAPS is ready to handle more
clients who abuse substances?