North East Multiple Needs and Exclusion Forum: Dual Diagnosis

Thursday 3rd December 2015The Dolphin Centre, Darlington

www.meam.org.uk | @meamcoalition | #multipleneeds

Welcome and Introductions

Introducing MEAM

• Three national membership orgs

• 1600 members

• Formed because of a recognition that people with multiple needs move between our sectors and are poorly supported

• Remit to focus on policy and practice change

Our vision…

In every local area people experiencing multiple needs are:

* Supported by effective, coordinated services

* Empowered to tackle their problems, reach their full potential and contribute to their communities.

Multiple needs definition

• They experience several problems at the same time such as mental ill health, homelessness, drug and alcohol misuse, offending and family breakdown

• They have ineffective contact with services

• And they are living chaotic lives

The national picture - what effects a person with multiple needs?

Other people, family, workers

Local services

Local commissioning structures, policies and strategies

National policies, commissioning and funding

Wealth redistribution, education, unemployment, stigma, etc.

7

The MEAM Approach

Getting started

Planning your implementation – service models and flexible responses

Sustainability

MEAM Approach Areas• Blackburn• North Tyneside• Sunderland• York• Mansfield/Ashfield• Oxford• Exeter• Norwich• Tamworth/Litchfield• Westminster• Wigan

More Information about MEAM visit www.meam.org.uk

North East Contacts:lindsay.henderson@homelesslink.org.uk

natalie.maidment@clinks.org

MEAM Local Networks Manager:george.garrad@homelesslink.org.uk

www.fulfillinglives-ng.org.uk

@fulllives_ng

#fulfillinglives #complexneeds

33% street homeless or sofa surfing

97% with substance misuse problems

94% with mental health needs

85% with a history of offending

Client support needs at time of referral:

What we found Nationally• 80-90% of clients accessing treatment services

have a mental health issue• 40-50% of clients access mental health

services have a substance misuse issue

What happens in practice for clients with co-existing mental health and substance misuse issues, and what expectations does the system have?

• In practice, mental health services often say ‘no’ to clients, for example the Crisis Resolution team, CMHT and Talking Therapies, if they are using substances problematically.

• D&A Treatment services feel there is a ‘black and white’ approach from mental health, for example, a client must STOP using substances (altogether) in order to access a MH service.

• There is only NICE guidance on psychosis and substance misuse, however it is often felt that all mental heath teams use these guidelines.

• There is a lack of flexibility from both treatment and mental health services – a client has to ‘fit in’ to what is being offered rather than the offer ‘fitting around’ the client.

• The Crisis Resolution team do not provide interventions for people under the influence and other parts of the system (e.g. housing providers or treatment services) often feel unsupported and unsure about how best to support/help the client.

• There can be a lack of communication between mental health workers and treatment services – no clear understanding about how they can work together to best meet the needs of the client in a joined up approach.

• There is an expectation that CPNs have the expertise to deal with dual diagnosis, but some say they do not.

• Although treatment workers do have training around mental health, they do not feel like the ‘professionals’ and do not feel equipped to deal with behaviours clients present and want more help from mental health colleagues.

What are the barriers?

• There is a need for formal diagnosis to access MH treatment but often chaotic clients have not engaged well enough to establish this.

• The waiting timescales to access MH treatment are often very long and chaotic clients need a more responsive service.

• The assessment of ‘capacity’ – the difficulty of establishing capacity for clients using substances.

• Corporate barriers – a lack of joint commissioning. • There are no information sharing agreements and difficult to promote

good communication • There are different assessment processes and a different ‘view’ on the

client – we are all dealing with the same person but see the person in a particular way depending on how we assess.

• Accountability – as mental health have statutory powers there is perhaps a feeling that accountability rests here and recovery workers looking for a statutory intervention to take the responsibility/accountability.

What would improve the journey for clients with co-existing mental health and substance misuse issues?

• Rather than definite decisions being made about whether a service can or cannot work with a client, have some offer of support and tailor it to the client’s needs at the time they need it.

• A more responsive service – chaotic clients often have a ‘window of opportunity’ which mental health cannot monopolise because of long waiting lists (detox, hospital, rehab etc).

• Co-location of recovery workers and mental health workers – a call for a ‘hub’ where clients can access both kinds of support simultaneously.

• Information sharing agreements• Common assessment tools (for example a common social-psychological assessment) and

standard risk assessments• Training – recovery workers may benefit from knowing more about Treatment Pathways

and Clusters. Likewise, a call for health care professionals to have training around addictions, engagement techniques, motivational interviewing and inspiration.

• Digital inclusion – using technology such as Skype to give workers more freedom about how to contact clients and allow clients with social anxiety to access services in the first instance, without the need to attend groups etc.

• Peer lead crisis resolution.

Case Study: Dual Diagnosis (mental health and Substance use)

Dual diagnosis case study

Case study GM: Gm was referred into fulfilling lives in February 2015 from a drug and alcohol treatment provider. GM is a 43 year old male who has served 18 years in the army as a staff sergeant, in charge of up to 200 officers. Upon his discharge he has been diagnosed with bi-polar type 1 and PTSD (April 2014) by a psychiatrist in London. GM is now also dependent on alcohol. Since moving to the North East GM has had contact with the Community mental health treatment team, dual diagnosis team and Crisis team, none of which have treated him nor recognised his past diagnosis due to his current alcohol use. MH services have stated they will not work with GM as they tend to follow NICE guidelines, stating a person must address their substance use before accessing MH services/interventions.

Outcomes and ongoing work

Through presenting GM’s case study (amongst others) to commissioners, highlighting the lack of support people with multiple issues are receiving from MH teams the following has occurred: Strategic task and finish group has been assembled including Adult Social Care, CCG lead,

Housing, Public Health, Drug and alcohol treatment, Mental health and fulfilling lives. The aim of this group is to manage expectations of service providers, present case studies in relation to when clients have been excluded from MH services and create a plan going forward that includes MH services working alongside treatment.

One LA has also reviewed their DRD (Drug Related Death) panel and now have a strong focus on dual diagnosis, exploring if and when a DRD has been referred into MH services (including crisis team), what the outcome was and what efforts were made to engage the person.

.

Questions/Reflections

Dr Sarala Barathy

Consultant Forensic PsychiatristSt Nicolas Hospital

Plan• Overview about dual diagnosis.• Implications.• Services available.

What is it• Concurrent mental health and substance use.• Wide range of mental illness.• Increased substance use being the cause.• Substance us as way to manage symptoms.

Implications

• Physical Health – infections etc.• Mental health – deterioration.• Social – isolation and homelessness.• Criminal justice involvement.

Strategies

• Focus is joint working.• Between various mental health services,

external agencies and voluntary organisations.• Be aware of mental health issues in drug users

and vice versa.

North East - NTW

• Drug and alcohol services at Plummer Court.• Community mental health services.• Forensic mental health services.• Mental and addiction services in prison.

Addictions service

• Based at Plummer Court, Newcastle.• Offer variety of services,• Multidisciplinary team• Out of hours• Day unit• In-patient• Joint working with medical specialities – antenatal clinic and

liver unit

Addictions service

• Harm reduction• Sexual health clinic• Psychological therapies• Family work

Group Exercise: Issue Analysis• Identify the Issue

• Work out the cause

• What are the likely impacts?

•What is your solution?

Issue Analysis

PIECES OF THE SAME PUZZLE?

Dual Diagnosis: a National Perspective

Andrew BrownConsultant (substance misuse) MEAM Coalition@andrewbrown365

Photo by Flickr user INTVGene

Definition

Source: A Guide for the Management of Dual Diagnosis for Prisons, Department of Health (2009)

How big an issue? Dependency & Treatment

Nationally there are an estimated• 1 million people dependent on illegal/illicit drugs, and • 1.2 million dependent on alcohol

Of which:• About 200 thousand adults in treatment for drug

dependency & 110 thousand for alcohol treatment.

Presence of co-morbidity in drug and alcohol services

Schizophrenia

Bipolar affective disorder

Non-specific psychosis

Personality disorder

Affective and anxiety disorders

Severe depression

Mild depression

Severe anxiety

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%Alcohol services Drug services

Source: Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive

The government estimate that 90% of adult prisoners had at least one of the following five mental health or behavioural disorders (personality disorder, psychosis, neurosis, and alcohol misuse and drug dependence).

Sources: http://www.theyworkforyou.com/wrans/?id=2014-09-05a.207561.h referencing ‘Psychiatric Morbidity among Prisoners in England and Wales’, ONS (1998)

NB this data comes from a 1998 survey, apparently it has not been repeated since

WHY IS THIS IMPORTANT?

Photo by Flickr user Declan Malone

Compounded Risk

People who have a dual

diagnosis have:

• More emergency admissions;

• Significantly increased rates

of psychiatric

hospitalisations; and

• A higher prevalence of

suicide than those without

comorbid mental disorders.

“Furthermore, clinical

practice has shown that

comorbid disorders are

reciprocally interactive and

cyclical, and poor prognoses

for both psychiatric

disorders and substance use

disorders are likely unless

treatment tackles each.”

Source: Comorbidity of substance use and mental disorders in Europe EMCDDA (2015)

Poor access to services made worse

“Ironically although the women we work with are chronically mentally ill, few of them have had treatment from mental health services. Their addiction is an insurmountable barrier to the mental health care which they desperately need. “Mental health services attribute the symptoms of their mental illness, however acute, to their addiction and signpost them to addiction services which they are too unwell to be able to engage with, so they are literally left out in the street.”

Source: Pippa Hockton, director and counsellor at the charity Street Talk writing on the Revolving Doors blog.

Long term Australian study

“In an 11-year follow-up of patients undergoing treatment for heroin dependence, 10.2% had died and almost half were still in treatment; the proportion still using heroin fell to a quarter, with major depression being a significant predictor of continued use.”

Teesson, M., Marel, C., Darke, S., Ross, J., Slade, T., Burns, L., Lynskey, M., Memedovic, S., White, J., and Mills, K. L. (2015), Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11-year findings from the Australian Treatment Outcome Study. Addiction, 110, 986–993. doi: 10.1111/add.12860.

Suicide• Only 7% of mental health patients who die by suicide

are receiving treatment for alcohol misuse, but 45% have history of alcohol misuse.

• About one in five drug misuse-related deaths in England and Wales is recorded as a suicide – this rises to one in four amongst women that die from a drug related death.

• Heroin users between three and four times as likely to die by suicide as the general population.

Sources: National Confidential Inquiry into Suicide and Homicide, ONS, and National record linkage study of mortality for a large cohort of opioid users ascertained by drug treatment or criminal justice sources in England, 2005–2009

Assessment of mental health provision by people in touch with the drug treatment

system

Whole sample Current OST user0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Psychosocial supportPoor or bad NeutalGood or very good

Whole sample Current OST user0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mental health treatmentPoor or bad NeutralGood or very good

Three in every five people in treatment for substance use problems is also suffering from a diagnosed mental health problem.

Concurrent treatment for substance misuse and mental ill health

London

North East

East of E

ngland

South W

est

South East

North W

est

Yorkshire

and the H

umber

East M

idlands

West

Midlands

0

5

10

15

20

25

30

35

For drug misuse For alcohol misuse

But on average across England about one in five people in treatment are having concurrent contact with mental health services.Source: Co-existing substance misuse and mental health issues Public

Health England

Variation in the North East

Sunder-land

Stockton-on-Tee

s

South

Ty-ne-side

Redcar and Clevelan

d

Northumberland

North

Ty-ne-side

Newcas-tle upo

n Tyn

e

Middlesbrough

Hartlep-ool

Gates-hea

d

Dar-ling-ton

County Durham

0% 5% 10% 15% 20% 25% 30% 35%

Alcohol Drugs

32%

Source: Co-existing substance misuse and mental health issues Public Health England

10%

WORKING OUT WHAT TO DO

Research evidence is scarce

“Establishing optimum care strategies, including where the treatment should take place (mental health facilities, substance abuse treatment facilities) and how best to treat these patients, is one of the biggest challenges facing policymakers, clinicians and professionals in the coming years.”

Source: Comorbidity of substance use and mental disorders in Europe EMCDDA (2015)

What might be important?• Engage people – be respectful, build relationships, use motivational

approaches• Recognise coexistence – routinely ask about substance use / mental

ill-health• Invest in workforce – ensure competencies up to date & clinical

supervision in place• Prevent exclusion – don’t let people with dual diagnosis slip through

the cracks• Joint working – mental health should provide care coordination• Ensure age-appropriate services available – young people’s needs &

care separate from adult care, think about transition• Work with families – negotiate confidentiality & information sharing,

point to support groups

Adapted from ‘Psychosis with coexisting substance misuse: assessment and management in adults and young people’ NICE (2011)

“A cultural change is required within the NHS and social care organisations to combat stigma and discrimination against people with addiction problems, and to ensure equity of care and delivery of effective interventions to address addiction problems and related health problems.

“Active participation of all healthcare staff is crucial to discharge responsibilities of duty of care – both duty to detect and duty to act.”

Photo by Flikr user UK in Japan- FCO

Source: Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence

Resources• Comorbidity of substance use and mental disorders in Europe

(EMCDDA) http://www.emcdda.europa.eu/publications/insights/comorbidity-substance-use-mental-disorders-europe

• Psychosis with substance misuse in over 14s: assessment and management (NICE) https://www.nice.org.uk/guidance/cg120

• The Leeds Co-occurring Mental Health and Substance use (Dual Diagnosis) Capability Framework http://www.dual-diagnosis.org.uk/wp-content/uploads/2011/09/Leeds-Capability-FrameworkFINAL2.pdf

• A Guide for the Management of Dual Diagnosis for Prisons (DH) www.nta.nhs.uk/uploads/prisons_dual_diagnosis_final_2009.pdf

• Coexisting Mental Health and Substance Misuse (DrugScope) https://drugscopelegacysite.files.wordpress.com/2015/06/coexisitingmhandsmfull.pdf

Thanks

Contact me…– a.brown@mind.org.uk

– @andrewbrown365

The estimated prevalence of adults living in private households in England having at least one psychiatric condition

16-24 25-34 35-44 45-54 55-64 65-74 75+0

5

10

15

20

25

30

35

'Psychiatric conditions' include the most common mental disorders (namely anxiety and depressive disorders) as well as: psychotic disorder; antisocial and borderline personality disorders; eating disorder; posttraumatic stress disorder; attention deficit hyperactivity disorder; alcohol and drug dependency; and problem behaviours such as problem gambling and suicide attempts.Source: http://www.theyworkforyou.com/wrans/?id=2014-06-10a.198856.h

Reasons given by providers for excluding at least one person from place of safety under section 136 in 2013

Intoxication

Disturb

ed behaviour

Criminal o

ffence

History

of Violence

Risk of s

elf-harm

ing0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50% “Under section 136 of the Mental Health Act 1983 (MHA), someone who appears to be experiencing a mental health crisis in a public place can be picked up by the police and taken to a place of safety for an assessment of their needs. In all but exceptional circumstances this should be in a healthcare setting…

“We are aware that health professionals are concerned that section 136 may be being used too much for people who are intoxicated, as they may not prove to have a mental health issue at all once sober. However, where police are concerned about someone’s behaviour, and believe that it may relate to a mental disorder, it would be wrong for them not to act on those concerns. This is a challenging issue, and we hope that the future edition of the MHA Code of Practice will be clear about the action to take in these circumstances.”

A safer place to be, Care Quality Commission (2014)Source: http://collateral.vuelio.uk.com/RemoteStorage/CSCI/Releases/588/20141021%20CQC_SaferPlace_2014_07_FINAL%20for%20WEB.pdf

Voices from the Frontline

Sam Thomas

Group Exercise: Research and Lobbying Plan

Issue Analysis

• Identify the Issue

• Work out the cause

• What are the likely impacts?

• What is your solution?

Issue Analysis

• Map key contacts & decision makers

• Identify key decision makers

• Assess decision makers and commers time lines

Research

• Develop a focused action plan

• Develop targeted briefings

• Request meetings with stakeholders

• Run seminars or focus groups

Lobbying Plan

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