Effective Approaches to Co-existing problems Christopher Brett Primary Care Link Worker Wellbeing Service (NSFT) Recovery Forum 6th June 2017

Where to start…and how to carry on What is Dual Diagnosis? What does it mean? How is it diagnosed? How prevalent is it? Risks Where to start…and how to carry on

Mentally ill chemical abuser Co-morbidity Co-occurring illnesses Concurrent disorders Dual disorder Co-existing Problems

What is Dual Diagnosis? Dual diagnosis usually refers to mental illness combined with substance misuse. May also be used to describe a number of other conditions, including physical health problems. In the UK social care sector, the term is sometimes used for people who have both a learning disability and a mental illness. (NICE 2016a) Dual diagnosis refers to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders, bipolar affective disorder and severe depressive episodes with or without psychotic episodes) combined with misuse of substances (the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage). (Nice 2016b)

Simply put… When someone with a mental illness also uses drugs, doctors call this ‘dual diagnosis’ (Rethink, 2017).

Drugs can make the symptoms of your mental illness worse. And sometimes this means… Drugs can make the symptoms of your mental illness worse. Some drugs may make it more likely for you to get a mental illness. There are many reasons why you might use drugs. Some people use them to try and deal with their symptoms. This is called 'self-medication'. Drugs can make your mental illness worse. They can make your illness harder to treat. (Rethink 2017)

The interplay between substance misuse and mental illness is complex and can change over time. It can vary between people and it may depend on the type of mental health problem and on the type and amount of substance misused. Someone may have: a mental illness that has led to substance misuse a substance misuse problem that has led to a mental illness 2 initially unrelated disorders (a mental illness and a substance misuse problem) that interact with and exacerbate each other other factors that are causing mental illness and substance misuse, including physical health problems. For the purpose of this guideline, dual diagnosis is defined (Nice 2016c)

Prevalence Recent studies have estimated prevalence rates of 20-37% in secondary mental health services and 6-15% in substance misuse settings (Carrà & Johnson, 2009). Between 22–44 per cent of adult psychiatric inpatients in England also have a substance misuse problem (NHS Confederation 2011)

May affect between 30 and 70 percent of those presenting to health and social care settings. (SCIE 2009)

Some risks to consider Increased likelihood of suicide More severe mental health problems Homelessness and unstable housing Increased risk of being violent Increased risk of victimisation More contact with the criminal justice system Family problems History of childhood abuse (sexual/physical) More likely to slip through net of care Less likely to be compliant with medication and other treatment.

Mental health and substance misuse problems are major public health and social issues. (SCIE 2009) Biggest challenge of our time (DoH 2002)

Trusting supportive relationships with professionals Where to start? A flexible, person-centred, empathetic, non-confrontational and non-judgmental approach which is important for maintaining an appropriate intervention programme Trusting supportive relationships with professionals Establishing a shared understanding Promoting optimism and building motivation Advice and information about the impact of substance use.

Understanding the chronology of the disorders, but maintaining a holistic focus in addressing the substance misuse, psychological, social and physical health problems Prioritising problem solving The relationship between dual diagnosis: substance misuse and dealing with mental health issues A harm reduction approach to substance misuse in the first instance (SCIE 2009)

Thinking about change

A few useful things to consider: Non-judgemental approaches Not getting too caught up with the “chicken and the egg” Understanding the relationship Developing a shared understanding of where the person is in relation to making changes to their substance use Multiple cycles Motivation Harm

Brief Interventions (B.I.) Quick & Effective! There is good evidence for brief interventions being effective in enabling people to make positive changes Health promotion Harm reduction Motivation Holistic Needs led Priority?

Does not condone or condemn Non-judgemental Education Advice Seeks to reduce/minimise harms Keeps people alive! Positives of change Negatives of change What can sustain motivation? What can put motivation at risk?

Joint Working Evidence suggests that where possible interventions are integrated when someone has co-existing needs. This doesn’t always translate to services, which remain split.

Multi-agency working Because people with co-existing problems often experience ongoing complex needs, focus on multi-agency working has to be a central concern. GPs Pharmacies Housing and social support Training/education/employment Charity/voluntary sectors

References Coexisting severe mental illness and substance misuse: community health and social care services (NG58) (Nice 2016a) Severe mental illness and substance misuse (dual diagnosis) – community health and social services – Draft Review 1 (Nice 2016b) NICE guideline: Severe mental illness and substance misuse (dual diagnosis): community health and social care services Scope (Nice 2016c) Mental Health policy god practice implementation guide (DoH 2002) Severe mental illness and substance misuse (dual diagnosis) – community health and social services (Dr. Odette Megnin-Viggars, Ms Marie Brown, Ms Elena Marcus, Ms Sarah Stockton and Prof . Steve Pilling 2015) RESEARCH BRIEFING 30: The relationship between dual diagnosis: substance misuse and dealing with mental health issues ( SCIE 2009)