Improving management of comorbid substance use and mental disorders with an integrated comorbidity management approach

Introduction and Aims: Despite the availability of effective management approaches for comorbid mental health and substance use disorders, such as integrated care, they are not commonly practiced. This body of work aimed to improve the management of comorbidity in outpatient drug and alcohol services through the implementation of an integrated care training program. The first aim was to conduct a comprehensive synthesis of the literature regarding implementation of evidence-based practice in drug and alcohol settings. A second aim was to develop and evaluate the impact of a training package to enhance the management of comorbidity by examining: i) screening, assessment and treatment of comorbidity, ii) clinician knowledge and attitudes, iii) barriers and enablers of the approach. A final aim included the identification of variations in barriers and facilitators of implementation between regional and metropolitan sites, and the evaluation of provider-level characteristics that influence implementation outcomes. Design and Methods: The first aim involved a systematic review of clinical and observational studies of strategies used to implement evidence-based psychosocial treatments for substance use disorders in drug and alcohol settings. Eligible studies were analysed using a qualitative synthesis of common themes derived from the Consolidated Framework for Implementation Research (CFIR)(1). For the second aim of the thesis, a training package was developed, substantiated by insights gained from the systematic review of evidence-based practice implementation in drug and alcohol settings. A controlled before-and-after study of the outcomes of training versus control, across 6 NSW Health drug and alcohol services was conducted. Three training sites were compared with control sites of similar geographic classification (i.e. metro, outer metro/inner regional, and regional). Training sites participated in a multi-modal training package (including 4 assessment time points) over 9 months. This included one day of seminar presentations on evidence-based treatment for 5 categories of substance use comorbidity delivered by experts in the field, fortnightly workshops led by local ‘clinical champions’, clinical supervision (telephone), and access to an online portal containing evidence-based information, manuals, tutorials, webinars, and ‘booster sessions’. Control sites received no training or resources throughout the 9 months. Primary outcome measures included identification, assessment and management of comorbidity, clinician self-efficacy, and knowledge and attitudes to comorbidity. Predictor outcome measures included clinician background, organisational readiness to change, and clinician attitudes towards evidence-based practice. Barrier outcome measures included the acceptability and feasibility of the training package and barriers to managing comorbidity and were subsequently coded according to CFIR constructs. Finally, variations in the barriers and facilitators of implementation between metropolitan and regional sites were identified by examining the differences in scores on CFIR constructs, and in addition, the association of provider-level characteristics with greater levels of practice change was assessed in order to determine predictors of implementation. Results: The systematic review indicated a lack of comprehensive implementation frameworks utilised in drug and alcohol treatment implementation research, and reiterated effectiveness of employing both ‘active’ and ‘passive’ strategies for implementation. The multi-modal Pathways to Comorbidity Care (PCC) package was developed accordingly, and a comprehensive implementation framework was utilised. The PCC package was found to be an effective means of improving the identification, and (to a lesser extent) management of comorbidity, and was found to significantly increase clinician counselling self-efficacy. Strong intervention characteristics (e.g. credible sources and evidence), inner setting domains (e.g. learning climate and leadership engagement), outer setting domains (e.g. patient needs), clinician characteristics (self-efficacy, knowledge and beliefs), and the use of clinical champions facilitated the implementation of the approach. Metropolitan clinicians reported more positive appraisals of the implementation compared to regional clinicians. The only clinician characteristic found to be associated with implementation outcomes included perceptions of leadership practices. Discussions and Conclusions: This thesis has provided a rich body of work that can be used to guide implementation of training programs designed to improve management of comorbid substance use and mental disorders in drug and alcohol services. Findings suggest that the PCC program effectively improved the management of comorbid substance use and mental disorders with an integrated comorbidity management approach. The systematic review findings validated the multi-modal design of the training package and application of the CFIR framework to the evaluation of the PCC program. This evaluation reinforced the importance of including both active and passive training strategies in implementation efforts, which need to be tailored to the specific needs of clinicians, while engaging all relevant members of the organisation and overcoming structural barriers. From a clinical perspective, the findings of this thesis support the notion of a future rollout of the PCC program in drug and alcohol services across NSW and Australia, which could potentially be implemented in the mental health context. Ultimately, this thesis represents an important contribution to translational research in drug and alcohol settings