Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Cutting Edge, 2010, Auckland, New Zealand, Friday, 24th September 2010 Professor Richard Velleman Professor of Mental Health Research, University of Bath / Avon & Wiltshire Mental Health Partnership NHS Trust, UK

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Acknowledgments: Amanda Baker, University of Newcastle, New South Wales, Australia Also, in Bath, Gina Smith, Ian Dickinson

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Three things today: • Huge range and high prevalence of co-existing problems; • Screening, assessing and intervening must become core business for health practitioners and health services; • Family approaches, and intensive work with people with co-existing homelessness as well as both mental health and substance misuse problems, are vital.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Huge range and high prevalence of co-existing problems One USA-based study: • any lifetime mental disorder, 29% ALSO had a lifetime history of some substance use disorder: • Conversely, any lifetime alcohol use disorder, • 37% ALSO had at least one other mental disorder (and 53% of those with a lifetime drug use disorder had at least one mental disorder).

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment If a Mental Health Disorder • Highest rates of alcohol or other drug use disorders were found among people with antisocial personality disorder (84%), followed by bipolar disorder (61%), schizophrenia (47%), affective (32%) and anxiety disorders (24%).

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment If an Alcohol Disorder • anxiety disorders (19%), antisocial personality disorders (14%), affective disorders (13%) and schizophrenia (4%). If a Drug Disorder • anxiety disorders (28%), affective disorders (26%), antisocial personality disorder (18%) and schizophrenia (7%).

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Are we hearing more about co-existing disorders? Yes: • the increasing availability and accessibility of alcohol and illicit drugs; • deinstitutionalization of people with severe mental health problems; • and increasing expectations that agencies will address co-existing problems.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Clients with co-existing problems can be hard to manage • Clients with co-existing problems can be ‘high impact’. • Often present a major challenge: their individual needs in medico-psycho-social terms, and their collective needs in organisational terms, are both complex and highly demanding.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Also, in economic terms: significantly higher overall healthcare costs than those with either substance use or mental health problems alone. • Many of these clients will have lost touch with (or have been discharged from) specialist medical, psychiatric and addiction services. • So they often pose particular difficulties for the non-statutory sector and for primary care.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment This creates a paradox: the services within which the staff are meant to have higher levels of skill in dealing with complex problems have tended to discharge or lose contact with these clients, and hence the ‘safety net’ services where staff often have lower levels of training are the ones that have primarily to deal with these complex problems.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment In summary, co-existing problems with both substance use, and one or more of a range of mental health issues (anxiety, depression, schizophrenia, bipolar disorder, etc) • are highly prevalent, • often begin in youth, • and place an immense burden on individuals, families, and society.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • Co-existing problems are associated with underachievement or failure for affected individuals across many domains, including academic, employment, relationship, social and health; • and with greater involvement with the criminal justice system, with failed treatment attempts, with poverty, and homelessness; • and the risk of suicide is also high.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Co-existing problems are so common that in clinical settings, a large proportion of presentations can be assumed to have such problems. Despite this, clinical services are usually separated along mental health and drug and alcohol lines; and clinicians have rarely been trained in how to detect, assess and formulate interventions for co-existing problems.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment So – most people with co-existing mental health and drug and alcohol problems do not receive optimal treatment. Example: delay in starting treatment - clinicians seek to establish a ‘primary’ diagnosis, often involving referral between different services. This is poor practice: detecting, assessing and treating co-existing mental health and drug and alcohol problems is the clinical responsibility of both mental health and drug and alcohol teams.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment What SHOULD HAPPEN? • All mental health and all drug and alcohol teams should be able to detect and assess symptoms of problems in both domains, and offer treatment for presenting symptoms. • Where both mental health and drug and alcohol problems are severe (for example, in the case of severe depression and alcohol dependence), I’d recommend treatment by only one team, in consultation with specialists in the other domain (if necessary).

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Terminology • This is an area where there are many debates about terminology, and underlying these are issues of professional power and control. • ‘Co-existing’ is a simple statement of fact. • symptom-focused and problem-oriented view of problems, not on whether or not problems are diagnosable. My orientation is to focus on individualized assessment and formulation.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Terminology • clumsy though it is, the term ‘co-existing mental health and drug and alcohol problems’ carries no allegiance to any professional group or source of institutionalised power, which is not the case with many of the other terms in general use at present – dual diagnosis, or co-morbidity.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Screening • Because such large numbers, often undetected • Profs must be alert to likelihood • And get familiar with useful signs: • Substances used for emotional regulation or side effects of medication, • low mood or mood swings, * loss of enjoyment in activities, • lowered functioning, * a significant shift in weight. • Sociodemographic factors may also alert workers, including • young age; * male gender; * family history of substance misuse; • homelessness; * disruptive behaviour; • poor family relationships; * repeated hospitalisations; • and legal difficulties.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Routine screening • risk of harm to self or others • screening for co-existing mental health and drug and alcohol problems and related areas. • Reluctance to discuss MH or D&A probs: likely to prejudice the outcome . • People reveal what they can, and do not reveal things that may be harmful for them

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Screening, assessing and intervening with clients with co-existing problems must become core business for health practitioners and health services; skills in this area needs to be a fundamental capability of practitioners working within both specialist mental health and drug and alcohol services.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Family Work • involving families where someone has an alcohol or drug problems leads to better engagement and better outcomes. • involving families where someone has an severe mental health problem ALSO leads to better engagement and better outcomes. • Not surprisingly then, family approaches can be just as effective when applied in cases where co-existing problems arise as they are when either problem presents on its own.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment The Stress-Strain-Coping-Support modal Family members are stressed due to the impact of a relative’s substance misuse How the family member copes with (responds to) the situation Strain: usually physical and psychological health problems and The level and quality of social support available to the family member

Family memberinvolvementwith the client Family memberstressors Clientoutcomes Family memberwell-being Family memberinvolvement in the treatment Conceptual framework for studying family involvement with adults with co-occurring substance and mental disorders (Townsend, Biegel, Ishler, Wieder & Rini, 2006)

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • Many of the ideas and skills utilized in one set of approaches are the same as those utilized in the other set. • Where differences, an opportunity to produce a family intervention using the best of both. • Motivational Interviewing (Miller/Rollnick) • Prochaska and DiClemente Cycle of Change • Tolerant family environments • Attributions • Expressed Emotion (over-involvement and criticality)

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment family interventions work best if they utilise all three of • an education process (helping the family members and the client understand better what is happening to the client) • the P & DiC Cycle of Change, • motivational interviewing. Process: promoting awareness of family interventions; referral; initial meeting; assessments; education; problem solving/ goal setting; evaluation; and booster sessions.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Co-existing Homelessness • homeless people have higher rates of both MH and substance misuse problems AND less access to services and other resources. • a model of care: designated, well trained and well supervised workers, work effectively across the various domains of mental health, substance misuse, and housing

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment The main elements • holistic (and pragmatic) view of targets • very high levels of skill in engagement. • Assessment should follow a similar process as for other clients; but individual barriers and organizational issues tto be addressed. • treatment can and should draw from all four relevant areas: substance misuse; mental health generally; assertive outreach in particular; and housing.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Gerry • 35 year old man, separated from and out of touch with his family. • Recently been released from prison for theft. • Extremely challenging and chaotic poly-drug user (heroin, alcohol, nicotine and other drugs, injecting where he could), • Sleeping rough • Experiencing psychotic symptoms. • Begging, shoplifting, theft, burglary

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • very difficult to engage; extremely distrustful; • gradually began to talk and allowed Ian to support him. • Night Shelter, primary health care check-up. • very long history of rejecting interactions with care and helping services. • anti-psychotic medication. • Ian: more overt therapeutic work, on both mental health difficulties, and his substance misuse.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Prioritizing the Therapeutic Work • Once Gerry had engaged sufficiently with the worker and the service such that initial physical health concerns and florid psychotic symptoms could be controlled, the worker was able to start to talk in more depth with Gerry about his concerns. • Gerry had already made significant progress, even to get to this point. Initially, distrustful, rather paranoid, not willing to enter ‘the system’ – the night shelter, the primary care team, and so on. • Even to start to talk about MH or substance misuse, was a huge step.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • “I'd like to be working, I would like to have contact with my children and I would like somewhere to live, just somewhere that I'm not feeling that if I meet someone in the wrong mood around me I can't be kicked out. That’s what I want, that is all, I'm not asking for much. Maybe I would ask for a bit of help to maybe look at things that have gone on in my life in the past.” • actual ‘sessions’ between Ian and Gerry, in private, without interruption.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Drug and Alcohol Work • methadone prescription ; oral, daily supervised consumption. • injecting behaviour; .gradually weaning off. • alcohol and cannabis use : much more difficult . Gradual opening of issues, working on concerns re money, shoplifting, and fear of returning to prison; and relationship between use of cannabis and exacerbation of psychotic symptoms.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Mental Health Work • paranoid; severe anxiety and associated agitation and aggression; depression. A number of psychosocial interventions: • taking ‘time out’ when felt defensively aggressive, and asking staff for help. • early symptom recognition and control, • medication management, • CBT work on unhelpful thoughts, • thought stopping and control, • relapse prevention.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Housing Work • Accompanying Gerry to the Housing Department, helping him fill in a housing application form.; letters to the Housing Department explaining Gerry's vulnerability : • eventually he was offered suitable accommodation. • Help in accessing furniture for his new flat via a furniture donation service.; helping fill in a Community Care Grant form for essential items such as a fridge and a cooker • Visiting him at home to ensure he was coping.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment The Role of the Past • Much of his first 16 years being moved from one institution to another; father: severe alcohol problem; Gerry: disruptive and difficult at a young age. • Parents found him difficult to cope with; child protection concerns re domestic violence. • At 11, into care, cycle of abuse and emotional neglect continued; series of children's homes, assessment centres and secure units; age 15 sniffing glue and stealing cars; at 17, into a flat but impossible to cope and began staying on friends' floors and sleeping rough.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • both psychiatric services and prison. • long-term relationship, 2 children, but fell apart : no contact with partner or children for many years; no contact with family of origin since aged 16. • Ian explored these past experiences ; started to help Gerry formulate some explanations for himself, as to why things had gone wrong, and how these were related to his current difficulties.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Outcomes • Gerry: still maintaining his tenancy; mental health and substance misuse are now stable. He says that the therapeutic work that Ian and others helped him with, have ‘given me a reason to get up in the morning’. • volunteers at a related project; developed skills; feels ‘100 per cent more confident’. • thinking about topping up his electrician’s training ; • not yet made contact with either family, but is still actively considering this.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment Key Factors in Successfully Helping Gerry. • Liaison between Ian and other staff /services; strong, consistent;facilitated effective multi-agency approach • no need to refer on to other services: ‘1-stop shop’ • Ian: high quality and regular support and supervision; excellent training; understood and could utilise a range of psycho-social interventions: CBT, MI, relapse management, and medication management. • very lengthy engagement period, where Ian persevered even though Gerry was adamant he didn’t want help.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment • Show huge range and high prevalence of co-existing problems; • Show how and why Screening, assessing and intervening must become core business for health practitioners and health services; • Shown something about how useful Family approaches are in this area • and demonstrated how intensive work with people with co-existing homelessness as well as both mental health and substance misuse problems, can be immensely helpful.

Co-existing Mental Health and Drug and Alcohol Problems: Steps towards better treatment