How well do international clinical guidelines on mental health and substance misuse address their coexistence? a systematic review of scope, quality and inclusivity

Abstract

Objective: It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review is to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance misuse in relation to diagnosis and treatment of such co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.Method: A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on ‘Appraisal of Guidelines for Research & Evaluation II’ (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.Result: A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnoses such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.Conclusion: Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

Clinical characteristics, attendance outcomes and deaths of homeless persons in the emergency department: implications for primary health care and community prevention programmes

“…[22][23][24] In addition, clinical guidelines for substance misuse and mental health need to be further inclusive to dual diagnosis as well as social and community cause and consequences such as homelessness. 25 Homeless people are known to be less likely to be registered with a mainstream general practice compared to the general population. 26 Documented cases of access being denied in primary care, contravening NHS England guidance, have come to light.…”

Navigating Schizophrenia Treatment: Balancing Symptom Relief and Long-Term Needs

“…Dual disorder, also known as co-occurring disorder or dual diagnosis, refers to the simultaneous presence of a mental illness and a substance use disorder (SUD) [42]. This condition is associated with a higher likelihood of negative health outcomes, including increased rates of suicide, unplanned hospital admissions, and premature death [43]. The repercussions of dual disorders may extend to violence, homelessness, interactions with the criminal justice system, and the disintegration of personal relationships [43].…”

“…A staggering 75% of individuals with a severe mental health disorder are also grappling with a substance use disorder [43]. Similarly, 60% of adults with a substance use disorder are diagnosed with at least one severe mental health disorder [43].…”

“…A staggering 75% of individuals with a severe mental health disorder are also grappling with a substance use disorder [43]. Similarly, 60% of adults with a substance use disorder are diagnosed with at least one severe mental health disorder [43]. Unfortunately, patients with dual disorders often receive incorrect diagnoses and inadequate treatment, slipping through the gaps in the healthcare system [42].…”

Clinical pharmacists in primary care general practices: evaluation of current workforce and their distribution

“…It is known that pharmacies and hence pharmacist workforce in the community is positively distributed with deprivation, with areas of higher deprivation having proportionately higher number and hence greater access to community pharmacies [24]. Pharmacists in the community provide services that aim to address inequality of care and to alleviate health impact of deprivation, including provision of minor ailment services, substance misuse service and medication reviews [25][26][27]. Innovative services to offer person-centred and integrated care to the most disadvantaged in the community, such as those with dual diagnosis of substance misuse and mental health problems, learning disabilities and persons experiencing homelessness are essential [28][29][30].…”