North East Multiple Needs and Exclusion Forum: Dual Diagnosis Thursday 3 rd December 2015

1. North East Multiple Needs and Exclusion Forum: Dual Diagnosis Thursday 3rd December 2015 The Dolphin Centre, Darlington www.meam.org.uk | @meamcoalition | #multipleneeds

2. Welcome and Introductions

3. 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 Introducing MEAM

4. 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. Our vision…

5. 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 Multiple needs definition

6. The national picture - what effects a person with multiple needs? Wealth redistribution, education, unemployment, stigma, etc.

8. Getting started The MEAM Approach Sustainability Planning your implementation – service models and flexible responses

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

10. 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

11. www.fulfillinglives-ng.org.uk @fulllives_ng #fulfillinglives #complexneeds

12. Client support needs at time of referral: 33% streethomeless or sofa surfing 97% with substance misuse problems 94%with mental health needs 85%with a history of offending

13. 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

14. 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.

15. 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.

16. 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.

18. Questions/Reflections

19. Dr Sarala Barathy Consultant Forensic Psychiatrist St Nicolas Hospital

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

21. 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.

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

23. 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.

24. North East - NTW Drug and alcohol services at Plummer Court. Community mental health services. Forensic mental health services. Mental and addiction services in prison.

25. 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

26. Addictions service Harm reduction Sexual health clinic Psychological therapies Family work

27. Identify the Issue • Work out the cause • What are the likely impacts? • What is your solution? Group Exercise: Issue Analysis • Issue Analysis

28. Dual Diagnosis: a National Perspective Andrew Brown Consultant (substance misuse) MEAM Coalition @andrewbrown365 Pieces of the same puzzle? Photo by Flickr user INTVGene

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

30. 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.

31. Presence of co-morbidity in drug and alcohol 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

32. 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). NB this data comes from a 1998 survey, apparently it has not been repeated since Sources: http://www.theyworkforyou.com/wrans/?id=2014-09-05a.207561.h referencing ‘Psychiatric Morbidity among Prisoners in England and Wales’, ONS (1998)

33. Why is this important? Photo by Flickr user Declan Malone

34. Compounded Risk People who have a dual diagnosis have: • More emergency admissions; • Significantly increased rates of psychiatric hospitalisations; and • Ahigher 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)

35. Poor access to services made worse Source: Pippa Hockton, director and counsellor at the charity Street Talkwriting on the Revolving Doors blog. “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.”

36. Long term Australian study 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. “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.”

37. Suicide 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 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.

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

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

40. Variation in the North East 10% Source: Co-existing substance misuse and mental health issues Public Health England

41. Working out what to do

42. Research evidence is scarce Source: Comorbidity of substance use and mental disorders in Europe EMCDDA (2015) “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.”

43. What might be important? Adapted from ‘Psychosis with coexisting substance misuse: assessment and management in adults and young people’NICE (2011) 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

44. “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

45. 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

46. Thanks Contact me… • a.brown@mind.org.uk • @andrewbrown365

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

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

49. Sam Thomas Voices from the Frontline

50. Group Exercise: Research and Lobbying Plan • Issue Analysis