Nature, level and type of networking for individuals with dual diagnosis: A European perspective more

Drugs: education, prevention and policy, Early Online: 1–9 Copyright ß 2010 Informa UK Ltd. ISSN: 0968-7637 print/1465-3370 online DOI: 10.3109/09687637.2010.520171 Nature, level and type of networking for individuals with dual diagnosis: A European perspective A. Baldacchino1, T. Greacen2, C.-L. Hodges1, K. Charzynska3, M. Sorsa4, T. Saias2, C. Clancy5, C. Lack6, E. Hyldager7, L.-B. Merinder7, J. Meder3, Z. Henderson5, H. Laijarvi4, & K. Baeck-Moller7 Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. Institute of Neurosciences, Centre for Addiction Research and Education Scotland (CARES), ´ University of Dundee, Dundee, Scotland, UK, 2Laboratoire de Recherche, Etablissement Public de sante Maison Blanche, Paris, France, 3Institute of Psychiatry and Neurology, Warsaw, Poland, 4 Department of Nursing Science, University of Tampere, Tampere, Finland, 5Department of Mental Health, Middlesex University, London, UK, 6Department of Psychiatry, Cambridge University, Cambridge, UK, and 7 Psychiatric University Hospital, Aarhus, Denmark and substance misuse (SM) issues) in recent years is reflected in the European Monitoring Centre for Drugs and Drug Abuse (EMCDDA) annual reports highlighting the difficulty associated with achieving Europewide integration of SM and MH treatment services (EMCDDA, 2004, 2005). In practice, different models of care have been developed with little being known about what actually works and for whom (Bucci et al., 2010; Chen, Barnett, Sempel, & Timko, 2006; Drake, Mercer-McFadden, Mueser, McHugo, & Bod, 1998). Integrated treatment, with seamless, holistic service addressing both the SM and the MH problem, has been largely promoted as a way of diminishing fragmentation, duplication and falling between the gaps arising from sequential or parallel treatment models (Lowe & Abou-Saleh, 2004). However, whilst the integrated model seems to have increasing policy support, the evidence is based on approaches from the US. It cannot be taken for granted that this model is necessarily the most appropriate for other countries (Flynn & Brown, 2008; Weaver, Renton, & Stimson, 1999). A Swedish study of treatment methods and co-operation/ ¨ co-ordination (Ojehagen & Schaar, 2003), inspired by the assertive outreach model used in the US (Drake et al., 1998), underlined the difficulties in developing proper teamwork. In Scotland, Hodges et al. (2006) reported service users being unable to obtain appropriate help even when they did gain access. Indeed, if a significant number of co-morbid individuals enter the care system at crisis point, then perhaps the more effective networks will be characterized by an 1 Aim: To obtain more detailed information on service availability and appropriateness and interagency networking for individuals with dual diagnosis (DD) at seven European centres. Methods: Data was collected using two parts of the three-part Treatment of Dual Diagnosis tool in seven European centres as part of the Integrated Services Aimed at Dual Diagnosis and Optimal Recovery from Addiction (ISADORA) study between 2002 and 2005 focusing on the nature, level and type of networking for individuals with co-morbid mental health and substance misuse problems (DD). A multi-level process of qualifying networking was used. Findings: Findings show that 50–90% of the listed centres across the ISADORA sites reported some level of networking but only 30% had a joint care agreement in place or shared patient/client records with at least one other agency. Barriers and facilitators to interagency collaboration are described. Conclusion: This pan-European study highlighted the need for a more integrated and focused approach to DD service delivery. INTRODUCTION Increasing recognition across Europe of the extent of dual diagnosis (DD) (co-morbid mental health (MH) Correspondence: A. Baldacchino, Institute of Neurosciences, Centre for Addiction Research and Education Scotland (CARES), University of Dundee, Dundee, Scotland DD1 9SY, UK. Tel: 0044 1382632414. Fax: 0044 1382633923. E-mail: a.baldacchino@dundee.ac.uk 1 2 A. BALDACCHINO ET AL. Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. ‘integrating pole’ that includes a crisis centre capable of directing clients to the appropriate centres and services required once the crisis has passed (Scottish Executive, 2003). Comprehensive needs and service mapping based on a common focused framework are essential to allow cross-boundary analysis and interpretation within and between countries. Various models offering an initial framework for identifying service development needs have been proposed: Comorbidity Programme Audit and Self Survey (COMPASS; Minkoff, 1991) developed for use in both MH and SM settings and, for the SM arena, the Integrated Dual Diagnosis Treatment Fidelity Scale (IDDT) by Mueser, Noordsy, Drake, and Fox, (2003) and the Dual Diagnosis Capability in Addiction Treatment (DDCAT) developed by McGovern, Matzkin, and Giard (2007). In the European context, SM treatments for co-occurring disorders seem often to be guided by conceptual models and clinical expertise or best practice guidelines rather than by research-based evidence (Baldacchino & Corkery, 2006). Overall, evidence is rather inconclusive and relatively little is known about organizational capacity to provide DD compatible services and treatment options. Furthermore, the EMCDDA underlines the need to evaluate the different treatment structures and service provision across European countries so as to allow practice to be underpinned by sound evidence (EMCDDA, 2004). Aims of the study The Integrated Services Aimed at Dual Diagnosis and Optimal Recovery from Addiction (ISADORA) project is a pan-European project carried out from November 2002 to October 2005. Seven sites across Europe collaborated on the project: Maison Blanche Hospital, Paris, France; University Hospital of Tampere, Finland; University of Dundee, Scotland; Institute of Psychiatry and Neurology, Warsaw, Poland; Middlesex University, London, England; Cambridge University and Peterborough Psychiatric Services, England and Aarhus County Psychiatric Services, Aarhus, Denmark. The ISADORA study had six aims: European centres, with a particular focus on the level and type of networking and obstacles and facilitators to effective interagency collaboration. Methods and materials Nature of surveys Data for this article were collected using two parts of the three-part Treatment of Dual Diagnosis (TODD) tool, an instrument describing treatment and support options for people with simultaneous SM and MH problems in a given geographical area. The TODD Overview of Centres (OC) consisted of a survey describing all centres across the research localities that could potentially provide any form of support for people with DD. This information was largely gathered through key informants with local knowledge of service provision, via the internet, annual reports and leaflets or pamphlets and, finally, through interviews with 50 patients at each site concerning service use. Its objectives were (a) to get an overview of health and social services that people with DD might use in the study area, (b) to understand the institutional context within which each centre functions, (c) to compare health and social services available to people with DD across the seven European sites, (d) to help researchers identify organizations mentioned by patients during follow-up and (e) to help identify ‘specialized’ centres for the second part of the TODD instrument, the Provider Zoom (PZ). The TODD PZ focused on those centres identified in the OC as potentially playing a key role in the management, support and/or treatment of people with DD in the study area. The PZ form was completed by a researcher after face-to-face or telephone interviews with a centre representative with substantive knowledge of their centre’s configuration and way of operating. Its objectives were (a) to collect additional data necessary for understanding patient pathways through care, (b) to describe the service provider point of view on the services they provide, on the way people with DD use them and on the usefulness of the services for this population, (c) to describe the intensity and nature of interagency networking and barriers and facilitators to interagency collaboration and (d) to compare availability and volume of service provision for DD, SM and MH clients in the seven European study areas. The third part of the instrument, the TODD User Zoom (UZ), used the mapping of centres and services provided by the OC and the PZ to allow a description of patient pathways through care and their experiences of care provision. Results from the UZ are described elsewhere (Greacen et al., 2010). Sampling and eligibility criteria Whilst all possible centres providing support or care of any sort for people with MH or SM problems were included for the OC, the PZ tool was only completed for those centres whose client profile included a significant . to map service options and care co-ordination for people with DD at the different European centres, . to describe pathways through care for people with DD at each site, . to evaluate changes in the social and clinical status of the sample population over a 9-month period, . to explore the views of staff and DD clients concerning obstacles and facilitators to service provision for this population, . to identify risk factors for the sample and . to develop a training programme for staff working with DD patients. This article will present results relating to the first of these six objectives: i.e. to map service options and care co-ordination for people with DD at the different NETWORKING IN DUAL DIAGNOSIS 3 Table I. Number of centres used by people with DD across ISADORA sites per 100,000 population. Centre focus 1. 2. 3. 4. 5. 6. 7. 8. 9. DD AM SM (other than alcohol) SM and alcohol misuse MH General health Criminal justice system SC Other Aarhus 4 10.5 12 5.5 37 4 1 32.5 1.5 108 Paris 0 5.5 3.5 4 15 12 0.5 21.5 0 62 Tampere 11.5 5 5 13 33 9.5 0.5 10.5 14 102 Dundee 0 7.5 3 7.5 14.5 4.5 1 18 1 58 Warsaw 0 8 3 3 10 19.5 1.5 11.5 3 59.5 Middlesex 0.5 4.5 4 5.5 48 14.5 3 6.5 10 96.5 Peterborough 0 4 4 3 29 10.5 6 36 5 97.5 Total Note: MH, mental health; SM, substance misuse; AM, alcohol misuse; DD, dual diagnosis; SC, social care. Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. number of people with either SM (including alcohol) or MH problems or both. A ‘significant number’ was defined as ‘at least 20% of service users should fit into one of these three categories’. Categorizing networking intensity Data were collected regarding the extent and nature of interagency working. Centre representatives were asked to name each agency their centre networked with, the intensity of the collaboration and for which interventions that agency might be called upon. Networking was assessed using the following scale: plans with regard to this population and the availability of training opportunities for professionals working in this area. RESULTS Service centres available to DD patients at the seven study sites Table I indicates the number of centres by their key focus, identified by the TODD OC, as being available to people with DD per 100,000 population at each of the seven ISADORA research sites. The study reveals considerable inter-site variation in the numbers and types of centres and services reportedly available to DD clients across these European research sites, with Dundee, Warsaw and Paris reporting from 100 to 124 centres and the four other sites from 184 to 216 centres. Of the available centres, 14 (1.2%) target DD, 242 (21.4%) focus on SM generally, 270 (23.9%) provide social services and 386 (34.1%) are MH centres. The remaining centres belong to other categories associated with general health and social care (SC). The ISADORA sites show major differences in concentration and level of specialization of centres, with 32.8% of centres reportedly accessible to people with DD in Warsaw being general health care providers, compared to only 3.7% in Aarhus. Aarhus, Tampere and Dundee have proportionally many centres specializing in alcohol misuse compared to other sites. Aarhus and Tampere also have the highest concentration of SM centres. Middlesex has the highest proportion of MH centres. Denmark and Peterborough have the highest number of SC services, with all but Middlesex showing a relatively robust ratio in relation to the population. Criminal Justice centres encountering a substantial proportion of DD clients are scant, with Middlesex taking the largest share. In Warsaw, DD clients, when they do enter the public health care system, appear to do so mainly via the general health sector. Level 1: Information provided (1) The recommended service is mentioned in a leaflet or pamphlet. (2) The service details are passed on to the client. Level 2: Nominative referrals and meetings between agencies (1) Appointments are made with the service on behalf of the client. (2) Meetings are held with the service to discuss particular clients. Level 3: Formal joint working (1) Client records are shared and joint working in addressing clients’ needs is in place. The levels are not mutually exclusive; nor does a higher networking level necessarily imply operation at a lower level. For some sites this is indeed the case; for others, the levels are viewed as different ‘types’ or ‘styles’ of networking rather than as intensity or quality per se. Qualifying barriers and facilitators to interagency work The final section of the TODD PZ asked the provider open questions about aspects of care provision and interagency networking for people with DD that might need improving, the existence of service policy or 4 A. BALDACCHINO ET AL. Table II. Extent of networking between centres at each ISADORA site. Aarhus Total number of centres Number and percentage of centres that indicate networking (%) Total number of network partners indicated Range (of network partners per centre) Mean number of network partners per centre 112 98 (88) 415 1–13 3.7 Paris 16 10 (63) 38 1–8 2.4 Tampere 138 125 (91) 1295 1–46 9.4 Dundee 19 15 (79) 95 1–9 5 Warsaw 12 5 (42) 23 1–4 1.9 Middlesex 20 17 (85) 84 1–18 4.2 Peterborough 53 49 (92) 225 1–15 4.2 Table III. Centres receiving and initiating most collaboration requests across ISADORA sites. Centres receiving most collaboration requests (centre code) Aarhus Paris Tampere Dundee Warsaw Middlesex Cambridge MH (3) Other (23) Other & SM/AM (50&67) SM/AM (8) AM (65) DD & MH (3&4) AM (74) Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. Number of Percentage of all Centres initiating most Number of Percentage of all collaboration collaboration requests collaboration collaboration collaboration requests requests (centre code) requests requests 45 9 60 13 4 13 27 11 25 4.6 14 17 16 13 MH (3&150) SM/AM (39) MH (65) SC (34) MH (35) DD (3) MH (57) 13 8 46 9 4 18 15 3 21 3.6 9.5 17 21 6.7 Note: Refer note of Table I. Nature of DD centres Only 14 explicitly targeted DD centres (i.e. only for people with DD) were identified and these were all situated at three sites: Aarhus Tampere and Middlesex. Centres including a DD service component were however also identified in Paris and Dundee: the centre in Dundee catered for complex needs, including simultaneous SM and MH problems; similarly, a drug misuse centre within a major MH care provider organization in Paris was specifically but not exclusively providing services to people with co-morbid drug misuse and MH problems. Data for Warsaw and Peterborough revealed no DD services or centres. Interagency networking Extent of networking Overall, 319 of the 370 centres (86.2%) identified in the PZ report some level of networking with at least one other centre. Over 85% of PZ centres in Aarhus, Middlesex, Peterborough and Tampere indicated networking with other centres. However, this was true for only 79% in Dundee, 63% at the Paris site and only 42% at the Warsaw site. Table II shows the extent of reported networking for each site. It is to be noted that this seemingly optimistic image for the majority of sites gives however no indication of the intensity or type of networking, nor of the relationship between intensity of networking and quality of care: the indicators described in Table II are necessary but not sufficient factors in meeting client needs adequately and appropriately. A specific analysis of results of the centre receiving or initiating most collaboration requests at each ISADORA site reveals that, at Aarhus and Middlesex, the centre that initiates the most interagency liaisons also receives the most offers (Table III). It is to be further noted that a high level of networking does not necessarily involve SM or MH: for example, in Paris and Tampere, two of the three centres receiving the highest number of collaboration requests (but not necessarily initiating most collaborations) could not be formally categorized by the PZ in any of the three key ISADORA target areas of SM, MH or DD and were subsequently categorized under ‘other’. Centres serving greater proportions of people with DD may have more extensive connections with other centres and services. Certainly, the centre representatives working for larger and more mature agencies generally reported greater connectivity. This was particularly visible at Aarhus and Tampere, where MH and SM centres rather than the DD centres exerted and received most offers of liaising. However, there was also some evidence to suggest that centres with larger proportions of DD clients may by necessity have developed a more intensive network involving inpatient, outpatient, MH and SC providers. Those centres with established care management mechanisms, including case management, care pathways and joint staffing, NETWORKING IN DUAL DIAGNOSIS 5 also seemed more likely to have linkages with a more extensive range of service provider types. Intensity of networking and provisions sought Table IV provides an overview of connectivity between centres for each ISADORA site. It describes the different kinds of services centres that network are seeking for each research locality, for each of three levels of networking. For example, of all networked centres in Aarhus at Level 1, 2% provide information to clients about other specific centres or do informal liaising for clients for basic needs, such as food or washing facilities, 27% for crisis interventions and 31% for psychological interventions. Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. resources within the network to address different individual client profiles. (2) Mastering networking skills, knowing how to negotiate bureaucratically organized treatment services and systems. (3) Knowledge of the needs of DD patients and of the resources available in the network. (4) Motivation to network: acknowledging one’s own role and responsibilities with regard to patients presenting with co-morbidity and having confidence in the services provided by other agencies. DISCUSSION Level 1 networking: ‘information is provided’ Across all ISADORA sites, 73% of centres that report networking are classed as networking at Level 1, i.e. they provide the client with information about other services so that he or she can make their own appointments. Within each ISADORA site, the picture becomes more fragmented. In Paris, this level of networking characterizes only 14 of the 27 (48%) networking centres, whilst in Warsaw all 23 networking centres, without exception, network at Level 1. Level 2: Nominative referrals and meetings between agencies Aggregated for ISADORA sites, 62.1% of centres that reported networking arranged appointments for clients or held meetings to discuss common clients with at least one other centre. Dundee centres were least likely to network at this level, with only 33% of network partner centres engaging in these sorts of liaising. Centres in Warsaw were most likely (83%) to collaborate in this way. Level 3: Formal joint working This highest level of interagency networking was infrequent. Only 31.5% of network partner centres across ISADORA sites were formally working in partnership at Level 3 with at least one other agency. Although some good examples of high level collaboration between specific centres were observed, results indicate that such comprehensive approaches were rare. Paris networking centres were least likely to network at this level (4%), compared to 43% of such centres in Tampere. Obstacles and facilitators to networking Analysis of PZ qualitative data from all participating countries revealed a significant number of barriers and facilitators to interagency collaboration (Table V). Four main interagency collaboration themes emerged: Although from 50% to 90% of centres at the different ISADORA sites report some level of networking, closer scrutiny taking into account the actual type and intensity of networking reveals that only 31.5% across all sites actually share patient records and have a joint care agreement in place with at least one other centre. Professionals’ opinions concerning the reasons for this low level of formal networking (Level 3) reveal a lack of clear policy and network organization that would allow coherent care pathways for clients, compounded by inadequate knowledge and skills about co-morbidity, leading in turn to poor motivation to make that extra effort to network. Joint working is patchy, with little routine contact and communication between services to co-ordinate assessments and care. Efforts to improve collaboration and share care between centres treating DD are often limited to a more informal level based on offering the client information and advice about other centres and how to contact these. These findings support those of Staiger, Long, and Baker (2010) who argue that the challenge to health and SC systems is to move away from short term and informal arrangements to formalized treatment systems responsive to the complexities and varieties of the DD cases presenting to a managed care network. With regard to maintaining sustainable DD service provision, the present results underline what Flynn and Brown (2008) and S. Sacks, McKendrick, J.Y. Sacks, Banks, and Harle (2008) identify as an urgent need to clarify the adequacy of current responses to DD by agreeing on core issues fundamental to delivering such services. Limitations Whilst the design and quality of research procedures to obtain current data was consistent across the ISADORA sites, the nature of relevant policy and system configurations differed considerably. This resulted in some differential interpretation of data collection and of categorization of service types and remits. Thus, for example, where services were included at one site, they may have been legitimately omitted at another and, as a consequence, data were not always directly comparable. A best estimate approach (1) The opportunity to collaborate, with policy, organizational and professional cultural contexts that allow or promote networking and sufficient Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. 6 Table IV. Percentage of networking centres seeking collaboration for different types of service provision for 3 levels of networking. Intensity level (%) % of networked Basic Crisis Psychiatric Psychology SM Psychiatric SM SM needs Intervention Advice Medical Outreach Intervention Outpatients Counselling Accommodation Inpatient assessment Detoxification centres Level 1 (Information provided) A. BALDACCHINO ET AL. A P T D W M Pe Level 2 (Arrange A appointments, P interagency meetings) T D W M Pe Level 3 (Formal joint working) A P T D W M Pe 2 – – – 5 – – 2 – 1 – – – 2 2 – 1 – – – 2 27 – 1 – 16 21 28 20 4 1 – 19 20 25 26 – 1 – – 20 12 8 15 2 11 5 36 71 8 22 9 13 6 35 61 6 – 2 8 – 47 49 4 – 9 33 11 27 29 7 4 8 32 13 27 30 2 – 7 60 13 21 16 61 – 8 3 21 49 50 50 – 8 7 25 51 54 57 – 10 – 25 40 60 31 15 2 – 42 53 46 28 17 2 – 38 50 42 26 100 2 – 75 37 47 6 31 1 7 5 20 13 5 22 1 7 6 17 11 4 – 3 – – 7 12 16 – 7 – 16 56 39 16 – 6 – 13 57 35 17 – 6 – 13 50 38 5 – 2 17 – 3 4 6 – 5 36 – 3 3 4 – 2 – – 7 3 3 – 3 – 11 25 7 18 – 11 – 13 23 4 24 – 22 – – 23 7 14 23 1 10 37 34 32 18 22 1 7 38 39 31 19 – 3 16 50 21 19 25 15 6 13 21 46 27 20 9 7 16 25 47 22 27 – 13 20 – 28 25 83 48 49 98 100 89 57 75 85 70 33 83 62 60 40 4 43 32 32 35 36 Note: A, Aarhus; P, Paris; T, Tampere; D, Dundee; W, Warsaw; M, Middlesex; Pe, Peterborough. NETWORKING IN DUAL DIAGNOSIS 7 Table V. Facilitating factors and barriers to interagency collaboration (networking). Domains (A) Opportunity Policy, cultural and resource factors Facilitators (Enabling factors) Long-term sustainable planning process supported by clinical and commissioners underpinned by good clinical governance Barriers Lack of resources (staff, time and money); No clear national or regional agenda; Lack of co-ordination of health authority programmes to enable interagency networking; Geographical spread and resulting logistic problems for creating systematic cohesion of services Lack of identified responsibility for co-ordinating pathways for people with DD; Lack of a clear legal mission with regard to interagency collaboration and objectives usually perceived as being too inward looking; Communication within services problematic; Differing professional values competing for care priorities; Rapid isolated changes in service organization and delivery; Staff turnover; Lack of tolerance for SM creating barriers to appropriate care and networking Patients’/clients’ autonomy and choice inhibit the referral process; Patients’/clients’ chaotic existence and resulting non-adherence to treatment plans leading to discordance; discontinuity and chaotic response by agencies involved, thus perpetuating further vulnerability Institutional factors, such as service organization and service delivery Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. Joint care provision planning based on identified shared aims and goals; Voluntary sector should be developed to improve capacity; A flexible, responsive system; A managed care network for DD; Consensus on sharing of information Individual factors, such as age, gender, ethnicity, type of DD Multiple pathways into treatment that are integrated and well-constructed, rather than being a result of patch work; Involvement of patients/clients and their families in the treatment process; Offering complimentary, psychosocial-based supportive activities run by all agencies in the area with the sole aim of tackling social exclusion Comprehensive assessment with ability to triage with other agencies Improve signposting; Enhance information from the internet, professionals and peers; Direct access to services, such as self referral Mondays to Sundays Improve the pool of competent service providers in the field of DD who are focused on delivering and co-ordinating best care (B) Skill The ability to express the need to network The ability to negotiate bureaucratically organized treatment services and systems ‘Splendid isolation’ Lack of signposting; Long waiting times causing lengthy delays and resulting fragmented responses by several agencies at once Different clinical approaches and philosophies create different expectations and knowledge based responses; Lack of lead clinicians and/or key workers in case conferences and multi-agency discussions; Lack of training in DD Confidentiality issues as a barrier; Lack of designated time for network (continued ) (C) Knowledge Sufficient information about problem and its treatment the Sufficient information about the partner networks Improve the informatics of patients’ profiles and movement between 8 Table V. Continued. A. BALDACCHINO ET AL. Domains Facilitators (Enabling factors) services; Designate time for network development; Organize multi-agency development groups to determine integrated care pathways and other clinical governance arrangements (e.g. policy and procedures, guidelines) Barriers development; Lack of feedback about individual cases to other agencies involved; Staff turnover (D) Motivation Acknowledgement of a problem and acceptance to act Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. Staff commitment to information sharing over and above referrals and liaison Lead clinicians in DD using a ‘consultative’ model and working in multi-agency settings; More outreach models of working practices Confidence in service provided by other agencies Actual belief in the recovery capital with real belief that improvement can happen Friendly non-judgemental and inspiring services working together for one core aim: to get the person better The ‘It’s not my problem or responsibility’ scenario; Unclear who should take primary responsibility for DD patients/clients Ignorance in other disciplines, agencies role and responsibilities with a mistrust of the actual value of their interventions creating lack of initiative to network; Professional silos; Lack of joint expertise or leadership models Attitudinal barriers toward DD; Low self esteem in treatment staff was adopted and only data that could clearly be delineated and compared were chosen for inclusion in this report. Despite widespread endorsement regarding the need for service availability and improvement, a lack of policy or systems perspective specific to DD across sites generally impedes such development. Thus, data concerning DD schemes, such as care pathways specifically designed for this client group and information regarding service co-ordination, is at best limited, restricting the ability to report accurately. CONCLUSIONS Future research developments should involve centre and service visits to yield data beyond self-report. A multi-source evidence base, for example observational data, team meetings, interviews and protocol/ guideline and minutes of meetings analyses, would allow for a more objective and independent insight into understanding how services operate when confronted with DD. ACKNOWLEDGEMENTS This study was supported by the European Commission, the Fifth Framework Programme, Cordis FP5 (Project QLG4-CT-2002-00911). We thank the service providers who participated in this study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. REFERENCES Baldacchino, A., & Corkery, J. (2006). Comorbidity research in Europe in perspectives across Europe. In A. Baldacchino & J. Corkery (Eds.), European collaborating centres in addiction studies (ECCAS) (pp. 307–330). London: St Georges Hospital Medical School. Bucci, S., Baker, A., Halpin, S.A., Hides, L., Lewin, T.J., Carr, V.J., & Startup, M. (2010). Intervention for cannabis use in young people at ultra high risk for psychosis and in early psychosis. Mental Health and Substance Use: Dual Diagnosis, 3, 66–73. DD is becoming a focus of attention for all service providers owing to the increase in numbers of service users with DD and the observed negative effects of inadequate service organization on these users and, in the broader perspective, on costs to society in general. This study underlines how the complexity of the needs of individuals with DD and the additional challenges they face in obtaining appropriate treatment demand a fundamental shift in the way MH and SM services are currently organized. The necessary client-centred approach produces challenges at all levels – from strategic, to operational planning, to delivery at the front line. Whilst it can be easy to talk about the concept of holistic care, the ISADORA study shows just how difficult it can be to co-ordinate inputs across many disparate services, each with its own culture and policy framework. NETWORKING IN DUAL DIAGNOSIS 9 Drugs Edu Prev Pol Downloaded from informahealthcare.com by Nyu Medical Center on 10/25/10 For personal use only. Chen, S., Barnett, P.G., Sempel, J.M., & Timko, C. (2006). Outcomes and costs of matching the intensity of dualdiagnosis treatment to patients’ symptom severity. Journal of Substance Abuse Treatment, 31, 95–105. Drake, R.E., Mercer-McFadden, C., Mueser, K.T., McHugo, G.J., & Bod, G.R. (1998). Review of integrated mental health and substance abuse treatment for patients with dual diagnosis. Schizophrenia Bulletin, 24, 589–608. EMCDDA (2004). Annual report: Selected issue 3: Co-morbidity: The state of the drugs problem in the European Union and Norway (pp. 94–102). Luxembourg: European Monitoring Centre for Drugs and Drug Addiction, European Communities. Retrieved from http://annualreport.emcdda.eu.int EMCDDA (2005). Co-morbidity: Drug use and mental disorders. Drugs in focus issue 14. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, European Commission. Retrieved from http://www.emcdda.eu.int. Flynn, P.T., & Brown, B.S. (2008). Co-occurring disorders in substance abuse treatment: Issues and prospects. Journal of Substance Abuse Treatment, 34, 36–47. Greacen, T., Baldacchino, A., Charzynska, K., Sorsa, M., Groussard-Escaffre, N., Clancy, C., . . . , Baeck-Moller, K. (2010). Pathways through care for people with dual diagnosis in Europe: Results from the treatment options for dual diagnosis (TODD) user Zoom instrument. Mental Health and Substance Use: Dual Diagnosis (in press). Hodges, C.L., Patterson, S., Taikato, M., McGarrol, S., Crome, I., & Baldacchino, A. (2006). Co-morbid mental health and substance misuse in Scotland. Edinburgh: Scottish Executive Substance Misuse Research. Lowe, A.L., & Abou-Saleh, M.T. (2004). The British experience of dual diagnosis in the National Health Service. Acta Neuropsychiatrica, 16, 41–46. McGovern, M.P., Matzkin, A.L., & Giard, J. (2007). Assessing the dual diagnosis capability of addiction treatment services: The dual diagnosis capability in addiction treatment DDCAT Index. Journal of Dual Diagnosis, 3, 111–124. Minkoff, K. (1991). Program components of a comprehensive integrated care system for serious mentally ill patients with substance disorders. In K. Minkoff & R.E. Drake (Eds.), Dual diagnosis of major mental illness and substance disorders: New directions for mental health services (pp. 13–27). San Francisco: Jossey-Bass. Mueser, K.T., Noordsy, D.L., Drake, R.E., & Fox, L. (2003). Integrated treatment for dual diagnosis: A guide to effective practice. New York: Guilford Press. ¨ Ojehagen, A., & Schaar, I. (2003). Mentally ill substance abusers in Sweden: A 5-year follow-up of a multisite study of co-operation between psychiatric services and social autho` rities. In G. Carra & M. Clerici (Eds.), Dual diagnosis: Filling the gap (pp. 49–54). Paris: John Libbey, Eurotext. Sacks, S., McKendrick, K., Sacks, J.Y., Banks, S., & Harle, M. (2008). Enhanced outpatient treatment for co-occurring disorders. Journal of Substance Abuse Treatment, 34, 48–60. Scottish Executive (2003). Mind the gaps: Meeting the needs of people with co-occurring substance misuse and mental health problems. Report of the Joint Working Group: Scottish Advisory Committee on Drug Misuse & Scottish Advisory Committee on Alcohol Misuse. Edinburgh: Scottish Executive. Staiger, P.K., Long, C., & Baker, A. (2010). Health service systems and comorbidity: Stepping up to the mark. Mental Health and Substance Use: Dual Diagnosis, 3, 148–161. Weaver, T., Renton, A., & Stimson, G. (1999). Severe mental illness and substance misuse. British Medical Journal, 319, 137–138.