Dual needs - Caring for those with mental illness and a drug dependency NSF (Scotland) Believes That there are significant numbers of people with mental illness who have also a drug dependency those with both conditions are not getting the best treatment there are a few good examples of how best to treat these conditions together in Scotland, we need more good practice, more pilot treatments in improving care and more research. Definitions Many people with mental illness also have other health problems. These may be physical (for example heart problems or diabetes), or they may relate to their misuse of substances - alcohol, glue, and prescribed or illegal drugs. This paper addresses particularly the issues of those with mental illness and a dependency on drugs. This is sometimes referred to as 'dual diagnosis'. However this term can be used for several 'dual' conditions and will not be used in this paper. We will also not distinguish between the situation when mental illness precedes substance (chemical) abuse (MICA mental illness chemical abuse) and CAMI where the opposite applies. There is still a big question of the actual relationship between the two conditions and much of the research points out the high level of misdiagnosis because of the difficulty of disentangling these. There are also a number of other issues such as how hospitals cope with illegal drugs on the wards, which will not be addressed in this paper. (Ref: Mental Welfare Commission report for 1996/97.) Background The Framework for Mental Health Services in Scotland identifies the need for services for people with mental health problems who misuse 'substances or alcohol'. There is a lack of data on how significant the problem is as most of the figures lump together drug and alcohol dependency and the combined rate may be as high as 66% (Hein et al 1997). A study in Nottingham suggested that for approximately half of those admitted for the first time with a substance abuse problem, the problem was with drug misuse (Cantwell et al 1998). Services are generally provided for mental illness or for drug dependency (with long waiting lists in some areas). There is no service available nation-wide to treat both conditions together. The National Schizophrenia Fellowship Factsheet 7 and the MIND publication 'Understanding Dual Diagnosis' give some general background. Treatment patterns There tend to be four approaches To treat the person first by one system and then by the other. To treat in parallel in both addiction and mental health settings, with associated problems of co-ordination and different treatment goals. An integrated approach, but this is rare in Britain, with few doctors trained in both fields suggested as a reason. The Institute of Psychiatry in London has set up a dual diagnosis course for mental health professionals but this appears to be unique. not to treat at all because the issues are too complex. Experiences of our staff working with users and carers: "I often come across a diagnosis of schizophrenia where previous drug history is also apparent. Often the mental illness is treated but the drug issues are not addressed beyond 'Don't do it'." "We spent months trying to get hospital services to help a service user who was severely mentally ill and also misusing drugs…. This man sometimes refused or avoided support, however, he was persuaded twice to go into hospital and was refused care. When queried, hospital staff responded that there was no point admitting him unless he agreed to stop misusing drugs." "From my previous experience as a drugs worker, in my opinion there are a great number of drug users who have serious mental health problems. I often encountered people who end up with little support from either drug or mental health services (each of these services stating that the other problem has to be addressed first)." "With some carers, their family member is taking street drugs as well as their medication. This is causing real concern with the carers who are feeling ill equipped to deal with an added problem." Examples of good care While the drugs problem continues to cause concern, there are a few examples of providing good care to people with these dual needs. Ayrshire and Arran Community NHS Trust has had a Dual Diagnosis Team since early 1997, consisting of a CPN, a staff nurse and four sessions of consultant time. They work within the addiction services. Issues to be resolved when a specialist team is in place include referral criteria, assessment and partnership arrangements with other agencies. Fife Care Management Project is an Intensive Outreach Team which works with small numbers of young adults with mental health problems exacerbated by alcohol or substance misuse. Specialist units such as the State Hospital have found that cognitive behavioural approaches have been effective for mentally disordered substance abusers. Assertive Outreach Teams have been developed in London as a Sainsbury Centre initiative to work with dual need in 'hard to engage' individuals. (Sainsbury Centre for Mental Health.) What is good practice? Running through much of the literature and current experience there is concern within forensic settings and with offending. It is clear that increased criminality is a high risk with dual need as is re-offending. Risk assessment is not well developed in substance abuse services despite the apparent association between substance misuse problems, mental illness and violence. (Ward and Applin 1998.) No single model comes over as best but the favoured options appear to be consecutive treatment or shared care, rather than parallel treatment from separate services. As indicated above, such care is being provided in only a few areas of Scotland. The service models from the U.S.A. have a more assertive aspect with teams working with small client numbers on a 24-hour basis. For example, in New Hampshire there are 'continuous treatment teams' on this basis. (Drake et al 1996.) There is often some coercion as well, such as compulsory treatment and programmes and control of welfare benefits, and there is reluctance here to use such approaches. It can be noted that some of the reports hint at high cost implications for such intensive interventions. Coping Strategies For Carers We have found no specific guidance to assist family and other carers of those with mental health problems who are also abusing drugs. The best guidance we have found is from NAMI, the USA National Alliance for the Mentally Ill. In this guidance the difficulty of identifying the additional problem is recognised. The need for a more gradual, less confrontational style for those with mental illness is urged. Families are urged to develop a plan of action: Agree that there is a proved drugs problem. Generate a number of solutions and agree on the best one(s) and seek assistance, from relatives, psychiatrist or CPN Come to an agreement about the best first approach. Take the plan forward with each family member knowing his or her role. Understand the possible effect of interaction with prescribed drugs. Advice can also be obtained from family groups associated with local Drugs Action groups. Research needs The main finding of this review, is the lack of knowledge and the lack of clinical models to address the issue. There are needs - to identify the scale of the problem of drug misuse and mental illness to identify the scope of the needs - which will differ between individuals at different stages in the illness and in the development of their drug misuse. to set up and evaluate pilot treatments in hospital and community settings as a nation-wide programme. There must also be a programme to evaluate the risks being produced to the individual and the community by the lack of care currently available to those with dual needs. NSF(Scotland) recommends that priority should be given to research into treatments basic training should be given to drugs workers and mental illness professionals to assist them to cope with people with dual needs best practice should be evaluated and established as a common standard in the medium term. References Cantwell et al (1998) 'Prevalence of substance misuse in first-episode psychosis' British Journal of Psychiatry. February 1999 Dept of Health et al (1991) 'Drug Misuse and Dependence: guidelines on clinical management', Department of Health, Scottish Office Home and Health Department, Welsh Office HMSO. Drake et al (1996) 'The course, treatment and outcome of substance disorder in persons with severe mental illness' American Journal of Orthopsychiatry, 66 Graham, Hermine' (1999) 'The role of dysfunctional believes in individuals who experience psychosis end use substances' Behavioural and Cognitive Psychotherapy, Volume 27 Hein et al (1997) 'Dual diagnosis sub types in urban substance abuse and mental health clinics' Psychiatric Services, 48 Jeffrey, Ley A et al (1999) Treatment programme for people with both severe mental illness and substance misuse Mental Welfare Commission Annual Report 1996/97 Meuser et al (1990) 'Prevalence of substance abuse in schizophrenia: demographic and clinical correlates' Schizophrenia Bulletin 16 MIND (1998) Understanding Dual Diagnosis NAMI (1993) Dual Diagnosis: Substance abuse and mental Illness Agnes B Hatfield NSF Fact Sheet 7 (1998) 'Dual Diagnosis - mental illness and drug/ alcohol problems' Sainsbury Centre for Mental Health (1998) Keys to Engagement Sciacca, Kathleen (1996) On co-occurring addictive and mental disorders (also has web site) Scottish Office (1997). A Framework for Mental Health Services in Scotland. Ward and Applin (1998) The Unlearned Lesson Wynne Howard Books Weaver et al (1999) 'Severe mental illness and substance misuse' BMJ 318:137-8 Recommended web sites www.nami.org (see also the article http://laami.nami.org/laami/dualdiag1.html) www.schizophrenia.com

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