What do you do with a patient who is both mentally ill and addicted to drugs or alcohol? Lynn Eaton on how the NHS is finally waking up to the challenge of dual diagnosis
It is a candid psychiatrist who will admit that they do not like treating certain types of people. But this attitude, unfortunately, is heard of all too often when it comes to patients with both a mental health problem and alcohol or drug addiction.
'No-one likes them,' says Coventry and Warwickshire Partnership trust consultant psychiatrist Dr Ashok Roy, who works in the Sutton Coldfield area. 'They are disliked by services.'
These patients, known as having a dual diagnosis, present some of the most difficult cases for treatment. It can be hard for staff to disentangle the addiction from the mental illness. And they may struggle to understand how someone can become addicted. Is the addiction causing mental illness? Is an addiction being used to self-medicate a mental illness? Where do you start with a treatment regime?
National director for mental health Professor Louis Appleby acknowledged the extent of the problem in 2002.
'Supporting someone with a mental health illness and substance misuse problems is one of the biggest challenges facing frontline mental health services,' he wrote in the Department of Health's Dual Diagnosis Good Practice Guide.
Research published by Imperial College in the same year suggested 22-44 per cent of adult psychiatric inpatients have problem drug or alcohol use. In high-security hospitals, 60-80 per cent of patients have a history of substance misuse prior to admission. And it has been suggested that fewer than 20 per cent of psychiatric inpatients with a substance misuse problem are being treated for it.
A main problem, Professor Appleby said, was that a number of agencies are often involved, such as statutory mental health services, specialist rehabilitation services and voluntary sector organisations. Historically, services for drug and alcohol abuse have been in the voluntary sector, with mental healthcare within statutory provision.
'As a result, care can be fragmented and people can fall down the cracks,' Professor Appleby wrote.
The 2002 guidelines were meant to alleviate that. They called for 'mainstreaming' of treatment for patients with dual problems in mental health services. Where specialist teams existed, they were advised to work with and support mainstream services. Staff in community-based assertive outreach teams should be trained to deal with dual diagnosis.
That was five years ago. Things may have improved a little, but the overwhelming impression, according to charities such as Mind and Turning Point, is one of services which - apart from a few centres of excellence - still fail to meet the needs of this demanding group.
Mind head of policy Marcus Roberts agrees that those with a dual diagnosis are very challenging to work with. 'Staff need a lot of support to do this effectively,' he says.
He is worried that there has been little monitoring of progress on implementing the 2002 guidelines. Mind is a member of the Dual Diagnosis Alliance, which has complained about the lack of follow-up on the issue.
'There doesn't seem to have been much follow-up at all,' Mr Roberts says. 'I suspect that some of the debate about personality disorder has taken over the momentum, although we are often talking about the same group of people.'
The reasons for the slow progress are complex. Reluctance of staff to deal with these clients, as suggested by Dr Roy, must be one.
The lives of these patients are often chaotic, with little or no family support, which makes conventional mental healthcare difficult to execute. They may have a criminal record (often the result of crimes committed to finance their habit). They may well have housing and employment problems too.
Add to that the lack of a suitable service and the scale of the problem begins to be understood.
One psychiatrist who worked in the NHS until three years ago but now works in the private sector admits that the NHS hospital where he used to work told patients who had a dual diagnosis to come back when they had dried out.
That temporarily got rid of the patient, but certainly not the problem.
Turning Point, one of the main charities that helps people who have drug, alcohol and mental health problems, has more insight than most into the service patients receive.
'It varies enormously from person to person,' says mental health policy and campaigns officer Caroline Hawkins. 'The treatment they will receive depends on the availability of services and the attitude of professionals.'
It also depends on where someone goes for help. 'They may present to a whole range of agencies,' explains Ms Hawkins. 'It could be a housing agency, or it could be their GP. Or it could be accident and emergency. Because they are falling through the gaps, they are often knocking on doors of quite a few services and not necessarily getting a good service from any of them.'
Once someone has come forward for help and got past workers' prejudices, they face another barrier. The health worker often tries to decide which of the two - or sometimes more - problems is the most important, rather than attempting to tackle both conditions in parallel.
'There is often a preoccupation with what comes first - the substance dependency or the mental illness,' says Ms Hawkins. 'Quite often people are batted back and forwards between services.'
Mental health services find it hard to work with people still using alcohol or drugs, she says. Drug or alcohol services may not be geared up to deal with what can be severe mental health problems.
In any case, deciding what exactly is going on is a bit of a chicken-and-egg situation.
'Dual diagnosis isn't actually a clinical diagnosis. It just describes someone with two or more co-existing conditions. People sometimes have confusing symptoms. The symptoms of some psychiatric disorders can be similar to those of substance misuse as well,' adds Ms Hawkins.
It goes beyond just treating an addiction or a mental health problem, she says. 'If someone is homeless or in an unstable relationship or has very few social relationships, that will impact on their mental health too.'
Although the government has called for more people in frontline mental health services, such as assertive outreach teams, to be trained in dual diagnosis, it is unusual to find such understanding elsewhere in the NHS. Dr Roy, for example, is not a specialist although, like many professionals, he increasingly finds himself dealing with people with more than one problem.
'Drug and alcohol-related problems are increasingly prevalent in our patients, as they are in our general population. The level of use has gone up. What has been defined as normal has changed. Nonetheless, I still don't think someone with an addiction will be dealt with sympathetically in mainstream services,' he says.
'Specialist units will take a more therapeutic approach by offering detox services. But what is most likely to happen [in mainstream services] is that a client will need to show they are free of any substances before they can get help for a mental illness.'
Although questions are routinely asked about drug and alcohol use as part of a clinical assessment when someone has a mental illness, that is often as far as it goes.
Clinicians may try to get the family involved and will probably make a referral to a clinical specialist, but such services are few and far between. In south Birmingham, for instance, there are two specialist psychiatrists to deal with substance abuse for a population of 800,000.
The need for appropriate treatment on dual diagnosis has been well documented, at least since a Commons health select committee report in July 2000 found it was crucial that greater priority be given to these patients. Guidance has been given to local implementation teams (LITs) to help put the 2002 guidelines in place.
The DoH has recently issued further instruction on how patients with mental ill health and substance misuse should be treated in hospitals. Aiming to tackle issues such as making inpatient wards and day hospitals free of non-prescription drugs and alcohol, it is currently open to consultation.
For all the talk, in 2002 only 8 percent of LITs had produced a plan to address the needs of people with dual diagnosis. By 2004, the latest date for which figures are available, this figure had increased to 17 per cent.
Care Services Improvement Partnership dual diagnosis lead Tom Dodd believes that most LITs now have the local agreements in place.
'We have a lot of evidence of good practice and examples of where the recommendations from the guidance have been implemented,' he says. 'Many areas now have specialist dual diagnosis workers in teams, such as assertive outreach teams, who have more expertise in dealing with this client group.'
He says there are also more training programmes targeted at mental health staff which will enable them to detect, screen and assess for drug and alcohol misuse more effectively.
Good practice examples
Meanwhile, Turning Point is putting together examples of 15 projects that are considered to represent good practice. Funded by the DoH, the project is due to publish its findings next summer.
There are three accepted models, says Caroline Hawkins. A serial model is one where one problem is sorted out before referring a patient on for the other. A parallel model is where staff from different disciplines provide separate treatments at the same time. An integrated model is where different professionals work as a team to treat both conditions at the same time.
'Just how far people have got towards an integrated model varies,' she says. 'It is important for other professionals, not just the specialists, to have the skills to deal with the problem - or at least to be able to recognise the problem and pass it on.'
Whatever the model adopted, working together is essential.
'People need to realise there is quite a lot of experience on both sides,' adds Ms Hawkins, who acknowledges that issues around professional boundaries need to be addressed.
Mr Todd is keen to see dual diagnosis dealt with in the mainstream, rather than in a specialist ghetto of care.
'We do have places where there is a real temptation to make it a very specialised service. My preference is that it should be everybody's business,' he says. 'Everybody needs to know something about working with this client group.'
Reaching out to isolated addicts
Turning Point runs mental health outreach projects in Cambridge and Hertfordshire that offer community-based support to people with mental health difficulties who have a history of drug and/or alcohol misuse.
Approximately 95 per cent of its caseload has a dual diagnosis. Most clients have a history of non-engagement with services, complex needs and chaotic lifestyles and are socially isolated.
Project workers visit service users in their homes and other community settings.
'We aim to support service users to develop the necessary skills and understanding to improve their quality of life in the community,' says a spokeswoman. 'We achieve this by tailoring our support to meet individual needs.'
Agencies that Turning Point works with include statutory community mental health teams, drug and alcohol services, inpatient units, the police, GPs, housing departments and benefits agencies.
Project workers draw up a personal support plan with clients to avoid concentrating on substance misuse alone. This can include support and advice on building social and life skills, budgeting, attending appointments, housing, benefits, education, employment or voluntary work. Support plans are reviewed every three months.
One client of the Hertfordshire team says: 'The thing I like most is that they have really treated me as an individual and haven't tried to fit me into a box.'
Personalised care at the priory
The Priory Group offers private residential treatment for people with dual diagnosis.
'The first thing we do is get a full assessment of the mental health problem,' says director of healthcare services Professor Chris Thompson. Clients are then asked about their drug or alcohol use.
'We have addiction counsellors within the hospital so we can refer a patient for help. The patient will be given a personalised programme, developed to include detox and take account of the relationship between detox drugs and psychiatric drugs. It's very simple to do both at once,' says Professor Thompson.
Someone diagnosed with, for example, both bipolar disorder and an alcohol addiction would immediately begin drug treatment for their mental illness. They would also start detox treatment for alcohol dependency, which takes a week to 14 days.
Some of this time would be spent in bed because the regime can be life threatening.
The client would then be visited by an addiction counsellor, who would offer cognitive behavioural therapy. Once they were well enough, they would attend group sessions.
The hospital bans non-prescription drugs and alcohol from the premises - something the latest DoH guidance on dual diagnosis calls for in the NHS. Patients sign a contract saying they will not bring banned substances into the hospital. If they do, their treatment may be stopped.